
Class _ ^(V-IMl. 

Book 2[hA°L 

Copyright N° 



COPYRIGHT DEPOSIT; 



A MANUAL 

OF 

FEVER NURSING 



WILCOX 



BY THE SAME AUTHOR. 



Treatment of Disease. A Manual of Practical Medi- 
cine. Second Edition. Octavo ; xxiv -f- 932 pages. 

Cloth, $6.00 net. 

" Dr. Wilcox's book is one that cannot be praised too highly 
and we unhesitatingly recommend it to the serious consideration 
of medical students and to practitioners, young and old, whose 
first and foremost desire is to cure their patients. The pure 
scientist, whose only interest is to study the nature of disease, 
may consult works on pathology, of which there is no lack, or 
some of the one-time popular works on practice, so-miscalled, 
but to the practical man, whose aim is to cure his patients, 
' The Treatment of Disease ' will be found most helpful and 
inspiring." — New York Medical Record. 

Pharmacology and Therapeutics. A Text-Book for 
Physicians and Students of Medicine and Phar- 
macy. Seventh Edition. Octavo ; ix + 885 pages. 

Cloth, $3.50. 

" The book in its present form will be even more popular 
than before/' — Therapeutic Gazette, 

" It is fortunate that the author is not only an active prac- 
titioner of medicine but a clinical teacher of physicians, fully 
alive to their special needs." — Post-Graduate, New York. 

Materia Medica and Pharmacy. A Text-Book for 
Physicians and Students of Medicine and Phar- 
macy. Seventh Edition. Octavo; ix + 490 pages. 

Cloth, $2.50. 

" It would indeed be difficult to lay one's hand on a book 
more admirably adapted to the purposes for which it is intended." 
— Therapeutic Record, Louisville. 

P. BLAKISTON'S SON & CO. 

PHILADELPHIA 



A MANUAL 



OF 



FEVER NURSING 



BY 

REYNOLD WEBB WILCOX, M.A., M.D., LLD. 

professor of medicine at the new york post-graduate medical school and 
hospital; consulting physician to the nassau hospital; visiting physician 
to st. mark's hospital; ex-president of the american therapeutic 
society; fellow of the American academy of medicine; 
member of the american medical association; vice- 
chairman of the revision committee of the 
united states pharmacopoeia ; etc. 



SECOND EDITION, REVISED 

Wlustratefc 



PHILADELPHIA 
P. BLAKISTON'S SON & CO. 

IOI2 WALNUT STREET 
I 908 






I LIBRARY of <3) 
Two Copies Kecwi 
APR 22 1908 

i 2* 6 //if 



Copyright, 1908, by P. Blakiston's Son & Co. 



Press of 

The new era Printing Company 

Lancaster. Pa. 



PREFACE. 

This volume contains the lectures on Fever Nursing 
which were delivered in substance to the nurses of St. 
Mark's Hospital during the season of 1907-8. It is 
believed that the subject has been very completely and 
comprehensively treated, and in accordance with the 
present state of practice. The w r ork of preparing the 
manuscript for the printer has been very conscien- 
tiously performed by Doctor Henry Hubbard Pelton 
and many practical suggestions have been made by 
Miss Annie M. Rykert, Superintendent of the Mar- 
garet Fahnestock Training School for Nurses of the 
Post-Graduate Hospital; to both of whom the author 
would extend his most appreciative acknowledgment. 

New York City, 
March, 1908. 



TABLE OF CONTENTS. 

Page 

PREFACE v 



CHAPTER I. 
Introduction. 
Definition of Fever : Causes : Physiology : Varieties : Lysis : 
Crisis : Recrudescence : Relapse : Normal and Abnormal 
Temperature : Symptoms i 

CHAPTER II. 
Diagnosis : Thermometry. 
The Thermometer: Scales of Thermometry: The Taking 
of Temperatures : The Pulse : The Respiration : Tem- 
perature Charts 19 

CHAPTER III. 
General Treatment: Diet. 
Hydrotherapy : Treatment of Special Symptoms : Feeding : 
Beverages : Diet in Convalescence : Diet-list 32 

CHAPTER IV. 
General Directions: Disinfection. 
The Nurse : The Sick-room and its Furniture : The 
Patient : Quarantine : Disinfection 65 

CHAPTER V. 
Infections of Continued Type. 
Enteric Fever : Paratyphoid Fever : Weil's Disease : 
Typhus Fever: Yellow Fever: Influenza: Malta Fever: 
Mountain Fever : Acute Miliary Tuberculosis : Chronic 
Pulmonary Tuberculosis 82 



CHAPTER VI. 

Infections of Continued Type with Local Manifestations. 

Pneumonia: Diphtheria: False Diphtheria: Acute Articu- 
lar Rheumatism : Erysipelas : Septicaemia : Puerperal 
Fever : Pyaemia : Mumps : Bubonic Plague 138 

CHAPTER VII. 

Infections of Intermittent Type. 

Malarial Fever : Relapsing Fever : Dengue 17 7 

CHAPTER VIII. 
The Exanthemata. 
Scarlet Fever: Smallpox: Chickenpox: Measles: Ger- 
man Measles : The Fourth Disease of Dukes : Epi- 
demic Cerebrospinal Meningitis 189 

CHAPTER IX. 

Thermic Fever. 
Heat Exhaustion : Insolation 218 

INDEX 221 



ILLUSTRATIONS. 

The Clinical Thermometer 19 

Specimen Temperature Chart (obverse) 29 

Specimen Temperature Chart (reverse) 30 



Clin 
Clin 
Clin: 
Clin: 
Clin 
Clin 
Clin 
Clin 
Clin 
Clin 



cal Chart of Enteric Fever 90 

cal Chart of Typhus Fever 113 

cal Chart of Yellow Fever 116 

cal Chart of Pneumonia 141 

cal Chart of Acute Articular Rheumatism 161 

cal Chart of Malarial Fever 180 

cal Chart of Relapsing Fever 185 

cal Chart of Scarlet Fever 192 

cal Chart of Smallpox 199 

cal Chart of Measles *. 210 



IX 



FEVER NURSING 



CHAPTER I. 



INTRODUCTION. 



Definition of Fever: Causes: Physiology: Varieties: Lysis: 
Crisis: Recrudescence: Relapse: Normal and Abnormal 
Temperature : Symptoms. 

Fever. — Synonym, Pyrexia. Fever, in the ordinary 
acceptance of the term, is understood to signify an 
abnormally high body temperature. In the present 
state of our knowledge, however, it must be considered 
as a group of symptoms caused by some derangement 
of the chemistry of the body which may be the result 
of a variety of causes. These causes may act from 
within, being generated in the body, or from without, 
having been introduced into the body. In either case 
they act by affecting the nervous system. For in- 
stance, fever may result from the failure of the body 
to throw off certain excrementitious products, as in 
cases of uraemic poisoning ; from certain changes in the 
blood, as in cases of anaemia; from exposure to ex- 
tremes of heat, as in sunstroke ; from various intestinal 
disturbances; from mental abnormalities, as in hys- 
teria. Most often, however, rises in temperature are 
due to the products of bacterial infection. The bac- 
teria, as they grow in the body, throw off certain poi- 



2 FEVER NURSING. 

sonous substances which are taken up by the circulating 
blood and affect the nervous mechanism which controls 
body heat. 

It is believed that in the central nervous system a 
centre or centres exist which control the heat produc- 
tion and the heat radiation (the two factors which 
regulate the temperature) of the body. Fever, there- 
fore, is the result of the abnormal working of this 
nervous mechanism. 

Heat production and heat radiation being responsible 
for the maintenance of a fairly constant body tem- 
perature, it follows that when variations from this tem- 
perature occur, they must be the result of abnormalities 
of these factors. Thus, fever may follow an increased 
heat production, a diminished heat radiation, or any 
other lack of proper ratio between the workings of 
these two functions. As a matter of fact, however, 
the most usual cause of fever is an increased pro- 
duction of body heat. Abnormalities of heat radia- 
tion are rare. 

The word " fever " is incorporated in the designa- 
tions of certain diseases of which, to the superficial 
observer at least, the chief manifestation is a rise in 
temperature. Of these diseases, which are sometimes 
spoken of as the essential fevers, typhoid fever may 
serve as an example. However, in these diseases, as 
in all others, the fever, that is, the high body tempera- 
ture, is merely a part of the clinical picture, or in 
other words only a symptom. 

Fevers are spoken of as continued, intermittent or 



INTRODUCTION. 3 

remittent. A continued fever is one in which the 
temperature maintains a continued high level with only 
slight variations. Typhoid fever may be taken as an 
example of this type. An intermittent fever is one 
marked by periods when the temperature may fall to 
normal, or even below this point, but only to rise again. 
Of this type ordinary malarial fever may serve as an 
example. A remittent fever is one characterized by a 
temperature continuously above the normal, and which 
falls and rises but is without intermissions. Remittent 
malarial fever may be considered as an example of 
this class. 

Again, fevers are classified as sthenic (dynamic) and 
asthenic (adynamic). A sthenic fever is one charac- 
terized by a hot, dry skin, thirst, full, strong, rapid, 
tense pulse, high temperature, and perhaps active de- 
lirium. An asthenic fever is one in which the skin 
is cold and clammy, the pulse feeble, and the nervous 
system depressed. 

In rare cases what is called an inverse fever occurs. 
In this type the elevation is highest in the morning and 
lowest in the evening, the opposite of the usual rule. 

The return of an elevated temperature to normal is 
known as the defervescence. This may take place by 
a gradual fall with intermissions during which there is 
a rise, but not to so high a point as that at which the 
fall began, and, as a rule, each successive rise is less 
than its predecessor; a defervescence of this character 
is called a defervescence by lysis. At the termina- 
tion of typhoid fever the temperature drops in this 



4 FEVER NURSING. 

manner. When a temperature falls to normal or be- 
low this point in the course of a few hours, the defer- 
vescence is spoken of as occurring by crisis. The 
usual defervescence in pneumonia is of this type. 

After defervescence has taken place a rise of tem- 
perature lasting for only a short time sometimes hap- 
pens; this is spoken of as a recrudescence. Such a 
circumstance is usually due to some insignificant and 
often unaccountable cause. When the fever and the 
other symptoms of the original disease return, it is evi- 
dent that re-infection has taken place, and this mani- 
festation is known as a relapse. To guard against 
the possibility of such occurrences, and in order that 
they may be immediately detected, it is wise to take the 
temperature at least once in the day, preferably in the 
evening, for a number of days after it has become 
normal. 

The temperature of convalescent persons is much 
more easily affected than that of those in health. 
Errors in diet, constipation, too much muscular exer- 
tion, or mental excitement are often followed by rises 
of temperature in such cases. A rise of three degrees 
or more may signify the onset of some complication or 
a relapse, and, consequently, should immediately be re- 
ported to the attending physician. Sudden falls in 
temperature are likely to indicate collapse. In apo- 
plexy and febrile diseases a considerable rise in tem- 
perature often takes place just before death, while in 
chronic wasting diseases the temperature may be sub- 
normal for a number of hours before the end finally 



INTRODUCTION. 5 

takes place. The temperature of infants and young 
children is much more easily influenced than that of 
adults, and consequently in them even slight constitu- 
tional disturbances may cause a fever of considerable 
height. 

The temperature is nearly the same in all parts of 
the body ; which may be accounted for by the fact that 
all parts are supplied by the blood, one of the functions 
of which is the distribution of heat. The average tem- 
perature of the human body in health is 98.6 F. 
(37° C.), but any temperature from 97.5 F. (36.5 
C.) to 99.5 ° F. (37.5 C.) is not considered abnormal, 
since body heat may be influenced by various factors 
even when disease is absent. The temperature of the 
body uninfluenced by disease may vary thus : 

(a) With the time of day. It is usually highest 
from four to seven o'clock P. M. Its maximum is 
maintained for three or four hours, when a slow and 
gradual drop begins, lasting until from two to six 
o'clock A. M., at which time its minimum is reached ; 
consequently at this time vitality is at its lowest ebb. 
As the morning progresses a gradual rise takes place 
until the normal 98.6 F. (37 C.) is reached. In 
persons who sleep by day and work at night the tem- 
perature is lowest in the evening and highest in the 
early morning. 

(b) With the performance of the body functions. 
There is usually a slight elevation after a full meal, 
due to the active performance of digestion, and also 
during muscular exercise ; though if at this time there 



6 FEVER NURSING. 

is profuse perspiration, there is, as a rule, a decrease 
in the temperature. 

(c) With the part of the body used in measuring 
the temperature. These variations are slight and of 
no importance. Rectal or vaginal temperature is 
slightly higher than that of the mouth or axilla. The 
sensation imparted to the hand by the feel of the body 
is no guide to the height of the body temperature, 
though at times fever may be suspected and later 
proven by the use of the thermometer. 

(d) With the age of the individual. In the infant 
it is slightly higher than in the adult and in old age it 
is a trifle lower, as the following table shows : 

Normal temperature in the infant.. 99.5°F. (37.5°C) 
Normal temperature under 25 years. 99 °F. (37.2°C.) 
Normal temperature about 40 years. 9&8°F. (37.i°C.) 
Normal temperature in old age 9&6 F. (37 °C.) 

(e) With the season of the year. The tempera- 
ture of the body is very slightly higher in summer 
than in winter. 

A temperature above or below the limits previously 
indicated signifies the existence of some abnormality 
of the functions of the body, and often the degree of 
the severity of this departure from the normal is in 
direct ratio to the height of the fever. The tempera- 
ture may, however, descend as low as yy° F. (25 C.) 
or ascend as high as 108 F. (42.5 ° C.) without death 
resulting, but such extremes, when maintained for any 
considerable period of time, almost invariably termi- 
nate life. Extraordinary cases are on record of very 



INTRODUCTION. 7 

low and very high temperatures. After long exposure 
to severe cold a temperature of 75 ° F. (24 C.) has 
been noted, and yet the individual has recovered, and 
cases of sun-stroke have occurred in which the tem- 
perature has risen to 112 F. (44.5° C.) without caus- 
ing death. 

In hospitals patients are sometimes found who will 
cause the column of mercury in the thermometer to 
rise to very unusual heights. This is accomplished by 
shaking the instrument or by rubbing its bulb upon 
the bed clothing. Such patients are usually maling- 
erers, and, if carefully watched, can be detected and 
prevented from practicing such deceptions. 

In shock, after haemorrhage, in certain forms of 
nervous disease, during marked alcoholic intoxication, 
especially if the individual has been exposed to cold 
and damp weather, and in any other condition pro- 
ducing a considerable weakening of vitality and a con- 
sequent condition of collapse, a subnormal tempera- 
ture may exist. 

The various ranges of body temperature may be 
classified thus: 

Temperature of collapse. 95 - 97°F. (35 °-36.i°C.) 

Subnormal temperature.. 97 - 98°F. (36.i°-36.7°C) 

Normal temperature 98 - 99°F. (36.7°-37.2°C.) 

Temperature of " fever- 

ishness " 99°-ioo°F. (37.2°-37.8°C.) 

Slight fever ioo°-ioi°F. (37.8°-38.4°C.) 

Moderate fever I02°-I03°F. (38.9°-39.5°C.) 

High fever I04°-I05°F. (40 °-40.5°C.) 

Intense fever io5°-io6°F. (40.5°-4i.i G) 

Hyperpyrexia io6°F. (4i.i°C.) and above. 



8 FEVER NURSING. 

An elevation in body temperature is, as a rule, ac- 
companied by certain symptoms referable to the vari- 
ous tissues and organs. Not all these symptoms show 
themselves in every case, they may not all be present 
in a selected case, but many of them are likely to be 
noticed in a patient who has any considerable rise in 
temperature. In certain diseases various of these 
symptoms may be particularly marked, and this fact 
often is of great aid in diagnosis. Instances in point 
are the conjunctivitis that usually accompanies measles 
and the sore throat that is a feature of the onset of 
scarlet fever. If the fever is caused by inflammation 
localized in any part of the body, there are usually 
manifestations which call the attention of both the 
patient and the observer to this part. For example, 
the pain in the chest, the cough, and the shortness of 
breath of pneumonia immediately suggest some inter- 
ference with the proper action of the lungs. 

Febrile diseases in the adult are usually ushered in 
by a distinct chill, with marked shivering, pallor, blue- 
ness of the lips, chattering of the teeth, and inability 
to keep warm, no matter how thickly covered, or by 
chilly feelings of greater or less severity. In the child 
it is often a convulsion, which may vary in intensity 
from slight muscular tremors of face and extremities 
to distressing movements of the entire body, which 
indicates the onset of fever. Following the initial 
chill or convulsion the rise in temperature, accom- 
panied by other symptoms, appears. 



INTRODUCTION. 9 

The Symptoms of Fever. 

Symptoms Referable to the Skin. — The skin is as 
a rule hot and dry and the patient complains that there 
is " fever " or that he " feels feverish," although it is 
quite possible for the temperature to rise to I02°-I04° 
F. (38.9°-40° C.) without being noticed by the patient. 
At times, and more often in some diseases than in 
others, the skin may be damp with a cool perspiration. 
Various eruptions associated with the different erup- 
tive fevers may appear. These will be described later. 

Tiny vesicles (water blisters) may show themselves, 
often in great numbers, upon various parts of the 
body; these need cause no alarm since they indicate 
nothing worthy of notice. Delicate skins often show 
a general rosy blush which pressure with the finger- 
tip causes to disappear, but which immediately reap- 
pears upon removal of the pressure. This phenomenon 
is probably due to an increased quantity of blood in 
the cutaneous capillaries. In the late stages of fevers 
the outer layers of the skin are likely to scale off. 
Especially is this a feature of the eruptive diseases. At 
times large pieces of epidermis may be peeled off, 
notably after typhoid fever, when the skin of the 
fingers or toes may come away almost intact, forming 
veritable " moulds " of the parts. 

Symptoms Referable to the Mucous Membranes. 
— The so-called " fever sore " {herpes labialis) is likely 
to be present, especially in malaria and pneumonia. 
There is, even early in fevers, thirst and a tendency to 
dryness of the mouth and tongue. The latter may be 



io FEVER NURSING. 

of brighter pink than normal or coated with a grayish 
or whitish fur, swollen, and often showing indenta- 
tions caused by the teeth. As the fever reaches its 
height the upper lip may be drawn back so as to show 
the teeth, and the tongue and lips become covered with 
a dirty, brown, foul, viscid deposit, consisting of food 
particles, cells from the lining of the mouth, mucus 
and bacteria, which is termed sordes. The lips may 
become fissured and the gums spongy and bleeding. 
At first the tongue may be coated only down its middle 
while its margin is redder than normal ; as the disease 
progresses the tongue may tend to become dry at 
night while it remains moist by day. When the fever 
becomes very severe it may be difficult for the patient 
to extend the organ, and it becomes tremulous, brown, 
dry, crusted and cracked. Bleeding from the fissures 
readily takes place. As the patient recovers, the tongue 
gradually assumes its normal appearance, which pro- 
cess begins at the tip and extends progressively back- 
ward. 

The pharynx is at first dry and may be the seat of a 
catarrhal inflammation ; the tonsils and fauces may be 
swollen or ulcerated. The characteristic appearances 
of the throat in scarlet fever, diphtheria, etc., will be 
described in the sections devoted to those diseases. 
The salivary glands may be swollen and tender. The 
mucous membranes of the nose and eyes are likely to 
be congested and their secretions may be increased. 
There may be nose-bleed, especially early in typhoid 
fever. 



INTRODUCTION. H 

Symptoms Referable to the Organs of Digestion. 

— The appetite is greatly diminished or entirely absent. 
The mere thought of food may be distasteful to the 
patient. At the onset of febrile disease nausea is com- 
mon and vomiting often follows. Gas in the intestines 
is a less common symptom. It usually causes little dis- 
comfort and may not be worthy of notice except in 
typhoid fever, in which disease it frequently occurs 
and is the result chiefly of a paralysis of the muscular 
coat of the bowel caused by the general infection, 
rather than that of the presence and growth of the 
bacteria in the intestine. Usually in fevers the bowels 
are constipated. Diarrhoea formerly was considered 
a marked feature of typhoid fever, but constipation 
is frequently present. 

Symptoms Referable to the Circulatory System. — 
The usual pulse of febrile disease is one of increased 
force and frequency and of greater resistance. As a 
rule the increase in these qualities is proportionate to 
the height of the temperature, as the following table 
shows, though in certain patients the acceleration may 
not be marked even with high fever. 

Temperature of 98°F. (36.7°C.) corresponds to a pulse of 60 
Temperature of 99°F. (37.2°C.) corresponds to a pulse of 70 
Temperature of ioo°F. (37.8°C.) corresponds to a pulse of 80 
Temperature of ioi°F. (38.4°C.) corresponds to a pulse of 90 
Temperature of I02°F. (3&9°C.) corresponds to a pulse of 100 
Temperature of I03°F. (39.5°C.) corresponds to a pulse of no 
Temperature of I04°F. (40 °C.) corresponds to a pulse of 120 
Temperature of I05°F. (40.5°C.) corresponds to a pulse of 130 
Temperature of io6°F. (4i.i°C.) corresponds to a pulse of 140 



12 FEVER NURSING. 

In children the pulse is particularly susceptible to 
rise of temperature, rates of 150 to 190 per minute 
not being uncommon. In adults a rate of no to 130 
is not infrequently observed, and it is often feeble ; in 
extreme cases it may become so rapid and weak as 
to be uncountable and impart merely a sense of undu- 
lation to the finger — the so-called running pulse. A 
dicrotic pulse (one with a double beat), an intermit- 
tent pulse, or one irregular in force and frequency, 
is an indication of heart weakness. Any sudden in- 
crease in the rapidity or weakness of the pulse is 
likely to indicate the onset of some complication. 
Position, muscular action, and emotional excitement 
influence the strength and rapidity of the pulse to a 
considerable degree. Consequently in fevers the re- 
cumbent position should be insisted on, for conserva- 
tion of the heart's strength may be a considerable 
factor in the preservation of the patient's life if the 
disease prove a protracted one. 

Symptoms Referable to the Respiratory System. 
In fever the number of respirations per minute may be 
slightly increased, and the depth of the breathing 
diminished, even when no lung involvement is associ- 
ated with the disease. There may be cough due to an 
accompanying bronchitis. When pulmonary involve- 
ment coexists, the respiration may be rapid, irregular 
and painful. In marked pulmonary disease the breath- 
ing may become very difficult or impossible when the 
patient is recumbent, and it may be necessary to allow 
him to sit up in bed with his back supported by a rest. 



INTRODUCTION. 13 

When cough exists it is often accompanied by expec- 
toration, the character of which will be described in 
the sections devoted to the febrile pulmonary diseases. 
Specimens of this should be retained for examination 
by the physician. 

Symptoms Referable to the Urinary System. — 
The urine of a beginning fever is less in quality than in 
health, of higher specific gravity, of darker color, and 
occasionally turbid. It may cause a burning sensation 
on being passed, due to its increased acidity. As the 
disease progresses toward recovery the quantity in- 
creases and the urine becomes more nearly normal in 
other respects. In convalescence the quantity may be 
even greater than in health. Fever urine, on standing, 
often deposits a red or reddish-brown sediment, con- 
sisting usually of uric acid or urates, which are the 
products of the unusual tissue changes which take 
place during febrile conditions. In severe febrile 
disease albumin, casts and even blood may appear; 
these, however, do not of necessity indicate permanent 
impairment of the kidneys. Retention of urine is a 
rare concomitant of fever. 

Symptoms Referable to the Nervous System. — 
The initial chill or convulsion of fever has been dis- 
cussed above (p. 8). When a chill manifests itself in 
the course of a fever it is likely to signify a sudden 
alteration for the worse in the patient's condition or the 
onset of a complication. Consequently such an event 
should be immediately reported to the attending physi- 
cian. The convulsion of beginning fever, as a rule, is 



14 FEVER NURSING. 

not the result of any change in the nervous system, but 
is caused by the poison of the disease. Convulsions 
developing later in febrile disease not involving the 
nervous system are rare, and may be due either to 
hysteria or to the presence in the system of substances 
which should have been eliminated through the kid- 
neys. Urinary examination may throw light upon the 
causation of such convulsions; hence it is important 
that the nurse should secure a specimen at the earliest 
opportunity. 

Headache is one of the most frequent symptoms of 
the onset of fever. It may vary from a dull ache of 
slight character to an intense, persistent and almost 
unendurable pain. At times it may be of neuralgic 
type. The pain is usually in the forehead or temples ; 
more rarely it occurs in the top or back of the head. 
As the disease progresses it is likely to abate in vio- 
lence. 

Pains in the back and limbs and in the bones are 
often associated with the headache, and also may vary 
in intensity from a mere discomfort to the severe pain 
in the back associated with smallpox or the marked 
bone-ache of epidemic influenza. 

Dizziness or vertigo often exists during the incep- 
tion of febrile disease. This is increased when the 
patient stands and is much relieved by the recumbent 
position. Patients recovering from fevers of pro- 
tracted length are frequently subject to dizziness due 
to weakness. 



INTRODUCTION. 15 

Mental symptoms are very common manifestations 
during fevers. These vary from mere dulness, listless- 
ness, apathy and indisposition to mental exertion to 
extremes of delirium, or even absolute coma. These 
symptoms differ with the temperament of the individ- 
ual ; intellectual persons and those who, in their daily 
occupations, are accustomed to use the mental rather 
than the physical faculties, are most likely to suffer 
from disturbances of this character. Naturally the 
type and severity of the disease influence to a marked 
extent the degree of mental disturbance. Extremes 
of mental disorder generally manifest themselves when 
the disease is otherwise at its worst. 

Delirium is not unusual in severe fevers and may, 
though rarely, exist from the onset of the disease. 
More commonly it occurs later and varies in degree; 
it may be mild and appear only at night ; it may be of 
quiet type or very violent, noisy, and so marked that 
restraint is necessary to control the patient. In other 
cases the delirium may be of the low, muttering type. 
When this occurs the patient lies quietly with his eyes 
open or closed, in a sort of half-waking state; he 
mutters incoherently to himself in a low tone, taking 
no cognizance of what is happening about him, and 
perhaps picks at the bed clothing or grasps at imagi- 
nary objects. He will respond sluggishly to a loud 
question and to active sensory impressions (a pinch or 
pin prick). He may make short replies, but soon re- 
lapses into his stupor, which may be troubled by dream- 
like hallucinations. These may disturb him even while 



16 FEVER NURSING. 

he is in a half-waking condition. While in this state 
restraint is unnecessary, but the nurse's vigilance must 
not for an instant be relaxed, for at any moment 
aggressive delirium of alarming character may appear. 
Habitual users of alcohol are likely, especially during 
the fever of pneumonia, to develop delirium tremens. 
Delirium of this type may attack even those who are 
unaccustomed to alcohol. Under this condition the 
patient talks constantly and incoherently. He is in 
motion continuously, there is marked muscular tremor, 
and he is unable to sleep ; he often shouts aloud, and 
frequently desires to rise, go out and attend to his 
work; visual and auditory hallucinations develop, and 
he may see various imaginary objects, especially ani- 
mals, such as rats, snakes or insects, particularly those 
which are disagreeable, and think that they are creep- 
ing about the bed. 

Delirium may pass on into stupor, a condition in 
which the patient lies quietly in a partially unconscious 
state, from which he may be aroused with some diffi- 
culty, but into which he slips again when the attempt 
to awaken him is discontinued; or a condition termed 
coma vigil may result. This is an unconscious state in 
which the patient lies with eyes open, but entirely ob- 
livious to all going on about him; he neither realizes 
nor can he express his desires, he mutters constantly, 
his lips and tongue tremble, and there are twitchings of 
his fingers and wrists (subsultus tendinum), due to the 
convulsive jerkings of their tendons ; he picks at the 
bed clothing and grasps at invisible objects. Such con- 



INTRODUCTION. 17 

ditions as these may gradually disappear as the patient 
progresses toward recovery, or absolute coma may 
supervene. This is a condition of entire insensibility, 
from which it is impossible to rouse him ; he lies prac- 
tically motionless, is unable to swallow, and passes 
faeces and urine involuntarily. Such a state is usually, 
although not invariably, a precursor of death. 

Hiccough (singultus) is at times an obstinate symp- 
tom of fever. It is occasioned by a spasmodic con- 
traction of the muscles of the diaphragm and may 
continue, despite energetic treatment, for considerable 
periods of time. 

Symptoms Referable to the Special Senses. — 
Taste. — In fever the sense of taste is rendered less 
acute, perverted, or, exceptionally, wholly lost. Noth- 
ing tastes good, thirst in increased, water is always 
acceptable, and sour-tasting foods and drinks are pre- 
ferred to sweet. 

Smell. — The sense of smell is frequently blunted, 
owing to the catarrhal inflammation of the nasal mu- 
cous membrane which may accompany fever. Espe- 
cially in typhoid fever, as mentioned, nose-bleed may 
be an early symptom. 

Hearing. — Hearing may be impaired, but is more 
usually rendered abnormally acute; there are often 
noises and ringing in the ears. Deafness is excep- 
tional. The infectious fevers may be complicated by 
inflammations of the middle ear. In such cases there 
is earache, which is lessened if the inflammation goes 
on to perforation of the drum-membrane. When this 



1 8 FEVER NURSING. 

takes place a discharge usually appears. At first this 
is thin, yellowish and perhaps bloody ; later it becomes 
thicker in consistency and often foul. 

Sight. — There is often a dread of bright light (pho- 
tophobia) , and vision is less acute than normal. Usually 
early in fevers the pupils are dilated ; later there is no 
fixed rule for their condition. Frequently the lining 
of the lids is inflamed ; its secretion is at first increased 
but later diminished, causing dryness. At times the 
lids may be gummed together. 

Fever is always accompanied by an increase of tissue 
waste; consequently emaciation to a greater or less 
degree is an inevitable result. This is all the more 
marked since, in addition to the tissue waste, there is 
disinclination on the part of the patient to eat and 
probably inability on the part of the digestive and 
assimilative powers to supply the increased need of 
bodily nourishment. 



CHAPTER II. 

DIAGNOSIS: THERMOMETRY. 

The Thermometer: Scales of Thermometry: The Taking of 
Temperatures: The Pulse: The Respiration: Temperature 
Charts. 

Diagnosis of Fever. — Fever being defined as an 
abnormal degree of body heat, the determination of 
its presence is made by measuring the temperature of 
the body. It is customary as well to note, at the same 
time, the number per minute and character of the pulse 
beats and respirations. The height of the tempera- 
ture is measured by means of the clinical thermometer. 



■■■ MM ■MM ^ ' ' ' ' " " ' I ' ' ' M ' ' ' ' ' ■ I ' ■ ' M ■ ' ' M I M l| 1 1 ■ ! t " 1 1 H I M [ I ) I IM I l I n n H ■ I n 

-g*~ .6 LLzoa -_a, *, g g . f 

Clinical Thermometer. 



• This little instrument is a form of maximum ther- 
mometer; that is to say, an instrument so constructed 
that when its column of mercury reaches a certain 
height it remains there until displaced by jarring or 
shaking. The object of this is to give the observer 
sufficient time for accurate reading. Some clinical 
thermometers are provided with a curved surface which 
magnifies the column of mercury so that it is more 
easily read than in instruments not so constructed. 
Thermometers registering in one minute or less may 
be purchased, but in hospitals those requiring from 

19 



20 



FEVER NURSING. 



two to five minutes are usually employed, since they 
are less expensive. 

There are in use at the present time three scales of 
thermometry, the Fahrenheit, the Centigrade and the 
Reaumur. The differences in these are as follows: 
while all are based upon the freezing and boiling points 
of water, the Fahrenheit scale takes 32 ° as the former 
and 212 as the latter, the Centigrade scale, o° and 
ioo°, and the Reaumur scale, o° and 8o°. A table of 
comparisons of these scales is appended. 



Fahr. 


Cent. 


Reau. 


Fahr. 


Cent. 


Reau. 


Il6 


46.7 


37-3 


86 


30 


24 


114 


45-6 


36.4 


84 


28.9 


23.I 


112 


44.4 


35.6 


82 


27.8 


22.2 


no 


43-3 


34-7 


80 


26.7 


21.3 


108 


42.2 


33-8 


78 


25.6 


2O.4 


106 


4I.I 


32.9 


76 


24.4 


I9.6 


104 


40. 


32 


74 


23.3 


18.7 


102 


38.9 


31. 1 


72 


22.2 


17.8 


100 


37.8 


30.2 


70 


21. 1 


16.9 


98 


36.7 


29.3 


68 


20 


15 


96 


35.6 


28.4 


66 


18.9 


I5.I 


94 


34-4 


27.6 


64 


17.8 


14.2 


92 


33.3 


26.7 


62 


16.7 


13-3 


90 


32.2 


25.8 


60 


15.6 


12.4 


88 


31. 1 


24.9 









Only the first two scales are in common use, the 
Fahrenheit in America and England, the Centigrade 
upon the continent of Europe; however, many physi- 
cians in the United State prefer to use the latter scale. 
Certain rules may be formulated for the conversion of 
one scale into the other; for instance, to convert a 
Fahrenheit reading into a Centigrade, one subtracts 32, 



DIAGNOSIS: THERMOMETRY. 21 

multiplies by 5, and divides by 9. To reduce a Cen- 
tigrade into a Fahrenheit, one multiplies by 9, divides 
by 5, and adds 32. Examples : 

98.6 F. = (98.6 — 32 X 5 -*- 9) = 37-0° C. 
37° C.= (37 X 9-^-5 + 32) =98.6° F. 

In the text of this volume the Fahrenheit scale will 
be used, with the Centigrade equivalent following in 
parentheses. 

The index upon a clinical thermometer usually reads 
from 95° F. (35 C.) to no° F. (43.3 C) or 112 ° F. 
(44.4 C), and each degree is divided into fifths, so 
that one accustomed to the use of the instrument may 
easily read as closely as to the tenth of a degree. 

With use the accuracy of clinical thermometers be- 
comes somewhat impaired, owing to the action of dif- 
ferences in temperature upon the glass; consequently 
it is wise from time to time to have them compared 
with a standard instrument. This may be done by 
holding both thermometers in a vessel of warm water 
and noting the difference in registration if any exist. 

In private practice each nurse should be supplied 
with two thermometers, to provide against breakage ; 
it is wise to keep one of these for mouth and the other 
for rectal temperatures. In hospitals, especially in 
contagious disease wards, there should be a thermome- 
ter for each patient, and the nurses should take great 
care not to break the instruments, as in a large insti- 
tution the cost of the thermometer supply is by no 
means a small item. When not in use they should be 



22 FEVER NURSING. 

kept in a small vessel, a tumbler for example, filled 
with an antiseptic solution (5 per cent, phenol (car- 
bolic acid) or 1 to 5000 mercury bichloride). The 
bottom of the vessel should be covered with a layer 
of absorbent cotton. Recently it has become possible 
to purchase thermometers in air-tight cases which may 
be filled with an antiseptic solution. The appliance 
is one to be recommended to those who carry the in- 
strument in bag or pocket. 

The temperature may be measured in the mouth, 
the axilla, the groin, the rectum, or the vagina. In 
ordinary practice the mouth or axilla is usually used. 
The temperature varies within small limits dependent 
upon the situation employed, as the following table 
indicates : 

Axilla (groin) 984°^. (36.9°C.) 

Mouth q8.6°R(37 °C) 

Rectum (vagina) 995°F. (375° c -) 

Before and after taking the temperature in any of 
these situations the thermometer should be washed in 
clean cold water, and the column of mercury shaken 
down as low as 95 F. (35 C). If the mouth is to 
be used, the nurse should make sure that no hot or cold 
substance has been eaten or drunk for some time 
previously. The patient should be told to keep the in- 
strument upon the floor of the mouth, underneath the 
tongue, to hold the lips tightly closed, lest outside air 
enter, and to breathe gently through the nose. If the 
thermometer is broken in the mouth and pieces are 



DIAGNOSIS: THERMOMETRY. 23 

swallowed, the physician should be notified imme- 
diately, although no bad results are likely to ensue. 

In using the axilla, the part should be wiped with a 
moist sponge or cloth, and then thoroughly dried with 
a towel. The bulb of the instrument should be placed 
in the deepest part of the arm-pit, the arm pressed close 
to the side, and the forearm folded across the chest 
with the hand upon the opposite shoulder. The nurse 
must hold the arm in this position while the thermome- 
ter is in place. 

When taking the temperature in the rectum, care 
should be taken that the bowel is empty, for if the 
thermometer does not come in direct contact with the 
mucous membrane it will not register the correct body 
temperature. The instrument should be lubricated 
with vaseline, or other like substance, and the buttocks 
gently separated with the fingers of one hand, while 
the bulb of the thermometer is inserted through the 
anal opening for from one-and-a-half to two inches. 
In struggling children and in delirious patients the 
nurse must take great care lest the instrument be 
broken within the bowel. When taking the rectal tem- 
perature of a restless child a safe method is to place 
the child with face downward over the knee and point 
the thermometer toward the umbilicus. Never leave 
a child while the rectal thermometer is inserted. In 
taking the temperature in the vagina the technique is 
practically the same as when the rectum is used. 

Taking the temperature in the groin is seldom nec- 
essary, and the results obtained there are less accurate 
than in any of the other situations. 



24 FEVER NURSING. 

It is wise to allow the thermometer to remain in 
place at least five minutes, so as to be certain of accu- 
rate registration. When there is local inflammation in 
or near the axilla, the mouth or the rectum, the local 
heat is increased over that of the rest of the body ; con- 
sequently in such case an unaffected part should be 
used in measuring the temperature. 

In every febrile condition the temperature should be 
taken at least twice during the twenty-four hours. 
Since the temperatures of the morning and evening 
indicate most exactly the progress and severity of the 
disease, these are the most appropriate times. In dis- 
eases of severe type it is customary for the physician 
to order the temperature taken every six, four or 
three hours, as he may deem necessary. Usually it is 
unwise to waken a patient in order to take his tem- 
perature, for the benefit derived from the sleep is 
likely to exceed that accruing from learning his tem- 
perature ; but at times it may become necessary to take 
the temperature at the stated intervals at all hazards. 
Decision upon this point is, of course, left with the 
physician. 

The Pulse. — In taking the pulse two factors must 
be considered, first, its frequency; second, its quality. 

The frequency of the pulse is affected by the same 
influences which affect the temperature (see p. n). 
It also differs in different individuals under the same 
conditions. One person in health may have a pulse as 
slow as 50 to 60 beats to the minute, while another's 
may beat 80 to 90. Age and sex influence the pulse- 
rate, as the following table shovrs : 



DIAGNOSIS: THERMOMETRY. 25 

Normal pulse in children... 90-100 beats per minute 
Normal pulse in adult males. 60- 75 beats per minute 
Normal pulse in adult fe- 
males 65- 80 beats per minute 

In noticing the quality of the pulse the following 
points must be considered : 

(a) Regularity or irregularity. 

(b) Whether intermittency be present. 

(c) The size of the artery. 

(d) The character of the pulse wave. 

1. Whether the rise be quick or slow. 

2. Whether the fall be quick or slow. 

3. Whether dicrotism be present. 

(e) The tension of the artery wall. 

(/) Whether the artery wall be abnormally thick. 

A pulse may be irregular in frequency, in force, or 
in both these elements. An intermittent pulse is one 
which drops a beat at regular or irregular intervals. 

The pulse wave as it is felt by the finger of the 
observer may rise and fall with varying degrees of 
rapidity. A dicrotic pulse is one in which two distinct 
beats are felt for each pulsation of the heart. The first 
and greater of these is the true pulse beat, and care 
should be exercised on the part of the nurse not to 
count the second and weaker pulse. In cases where it 
is difficult to distinguish the true beat from the false 
one the hand should be placed on the chest over the 
heart's apex. When this is done the dicrotic pulse 
may be counted with ease and correctness. In this 
type of pulse, which occurs only when arterial tension 



26 FEVER NURSING. 

is low, the second wave is due not to a contraction of 
the heart, but to the closure of the aortic valves. 

The tension of the artery wall depends upon two 
factors: Whether the muscular coat of the artery be 
contracted and whether the vessel be fully distended 
with blood. A pulse of high tension is not easily com- 
pressible by the finger and its condition is analogous to 
that of a rubber tube well filled with water under heavy 
pressure. 

Thickening of the artery wall is determined by press- 
ing the vessel, in order to empty it of blood, and then 
trying to roll it under the finger-tips. If the empty 
vessel is more than slightly perceptible, its wall may be 
considered as thickened. Thickness differs in degree 
from bare perceptibility to such marked thickening 
that the vessel feels like a pipe-stem under the skin. 

The normal pulse is perfectly regular in force and 
frequency with an artery of medium size, whose rise 
and fall are gradual, whose tension is only moderate, 
and whose wall is not thickened. 

Under normal conditions some individuals have an 
intermittent pulse, but such a condition is not a fre- 
quent occurrence. 

Impairment of the strength of the pulse, increase in 
its rapidity, intermittency and dicrotism, are indica- 
tions of heart-weakness, and are not unusual mani- 
festations in febrile disease. 

The nurse should be watchful of the effects upon 
the pulse of various therapeutic measures, such as baths 
and the different drugs. In disease, pulse and tern- 



DIAGNOSIS: THERMOMETRY. 27 

perature bear an important relation to one another, 
pulse frequency being increased as a rise in tempera- 
ture takes place; any disturbance of this ratio should 
be carefully noted by the attendant, since it may be an 
indication of heart weakness. 

In taking the pulse the radial artery in the wrist is 
the usual site for the procedure, although at times the 
carotid or temporal arteries may be found more con- 
venient. The nurse should accustom herself always to 
use the same fingers, usually the index and middle 
fingers of the right hand, because continued practice 
will result in extreme delicacy of touch. The pulse 
should be counted for at least one minute in order to 
insure accuracy. 

The Respiration. — In taking the respiration of a 
fever patient, as in taking the pulse, frequency and 
character are the elements to be noted. Normally the 
number of respirations per minute in the adult is in 
the neighborhood of eighteen, or one to about every 
four pulse-beats. The rapidity of respiration varies, 
as does that of the pulse, at different periods of life. 

Respirations in the infant 30-35 per minute 

Respirations in the child from 

five to eight years 20-25 per minute 

Respirations after eight years 

of age 18-20 per minute 

The normal pulse-respiration ratio may be modified 
in disease. In fevers without lung involvement the 
pulse usually undergoes a greater relative increase than 
the respirations, while in cases in which the lungs are 



28 FEVER NURSING. 

affected the reverse of this rule is the usual condition. 

In observing the respirations the following charac- 
teristics should be noted : 

(a) Their frequency. 

(&) Their regularity. 

(c) Their depth. 

(d) Whether they be quiet or stertorous. 

(e) Whether they be abdominal or thoracic. 
Stertorous respiration is breathing accompanied by 

a sound resembling snoring. 

In children and adult males respiration is normally 
abdominal, that is to say the abdomen, rather than the 
chest, rises and falls upon inspiration and expiration; 
while in adult females thoracic respiration — breathing 
in which chest movement is more marked — is the rule. 

While taking the respiration the nurse should not 
allow the patient to know what is being done, for this 
knowledge is likely to have such a mental effect as to 
influence the depth and rapidity of the breathing. 
Usually the respiration can be counted by watching the 
rise and fall of the chest or abdomen of the patient 
without his cognizance. In order to insure an accurate 
record the respirations should be counted for at least 
one minute. 

In children the act of crying frequently renders it 
quite impossible to estimate the respirations with any 
degree of accuracy. 

For recording the temperature, pulse and respiration 
printed or ruled charts are used which not only show 
at a glance the course of the disease in regard to these 



DIAGNOSIS: THERMOMETRY. 



29 



factors, but are valuable afterwards as documents of 
reference. Such a chart is depicted below. The method 
of recording the temperature, pulse and respiration is 



Name 








Age 






.Sex. 




Diagnosis 
















.Case Nc 


- 


DATE 
















42° 


DAY' OF 

DISEASE 
















HOUR *• 


M. P.N 


LU. 


P.M. 


A.M. 


P.M. 


A.M. 


P.M. 


A.M. 


P.M. 


A.M.. 


P.M. 


A.M 


P.M. 






- i 1 


1 1 


1 1 


1 1 


| | 










1 1 


■ 
















. 1 












1 
























! 1 




















41° 














































































































































































1 








































































. ; 












































40° g 
























I 










































































.c 


















' 
















a J =._ 






































© c 






































a 104 - 




H— 


















■ 1 | 
















e3 " " ' 

- 




[— 




















1 1 


1 






1 1 










e 


















































































1 ! 










































































































1 i 












' 




























H 102 -: 












1 1 
















I ' 










Z ": 
























- 




p 










O 

a 

s 

38°? 






















. 




" 1 












§ 101 « 








































t , 


























s -- 
































w _ c : 
































H 100 - 




1 ' 




























O 






I 
































































i 1 




























































99 : 






































1 1 


























— — r— »- 

































36° 


98 - 
































































































































































97 - 
















































































































































































96 1 


















































































































60 






















■ 


























































50 


140 




















1 








































, 




















130 




























































1 




















40 oj 












































hJ 




























K 110 " 


A 




n \ 


























°2 inn - 


' 


v V 


\ 


























30 > 


.J 100 r 


/ 


\f 






























f 






V 
























t. , 90 • 








V 
























































O 
20 « 


80 




Lk 


V 




























- •' ' ■■■> 


■"< r-* 


XJ 


























_7^ ^' 






\ 


























































10 














































































































I 
























1 






























, 


















1 | 


















NO. OF 
STOOLS 












! 
















II 


1 
1 1 


i 




! 












il 



as follows : Suppose the patient is first observed in the 
morning and his temperature is 101.2 F. (38.5 C), 



3° 



FEVER NURSING. 



his pulse 95 beats per minute, and his repirations 20 
per minute ; dots are made upon the chart in the proper 
places. In the evening his temperature is found to 
be 1024 F. (39.1 C.)> his pulse 115, and his respira- 
tions 25 ; dots are again made in the column for after- 
noon records, and lines are drawn connecting these 



Examination 
of Urine 



Oz. 



Remarks 



Medication 



Diet 



General 
Remarks 



DIAGNOSIS: THERMOMETRY, 3 1 

with those of the morning/ The next day the process 
is repeated, and so on during the period of illness. 
When the records are taken more often, the method 
is the same, the chart being so arranged as to make 
the recording of the patient's condition every four 
hours very simple. Upon the right side of the chart 
will be found Centigrade and respiration scales. It is 
well to chart the night temperature curve and the res- 
piration curve in red ink. The spaces for date, day of 
disease, and number of stools will explain themselves. 
Upon the back of the chart {see opposite page) will 
be found spaces for recording the urinary examina- 
tions, the medication, the diet, etc. It is suggested 
that the notes for the night be made in red ink. 



CHAPTER III. 
GENERAL TREATMENT: DIET. 

Hydrotherapy: Treatment of Special Symptoms: Feeding: 
Beverages: Diet in Convalescence: Diet-list. 

General Treatment of Fever. — At the first indica- 
tion of febrile disease the patient should be put to 
bed, in the recumbent position, and strict quiet en- 
joined. The problems that confront us in the manage- 
ment of such a patient are two: first the removal of 
the cause and underlying factors so far as this is pos- 
sible, and, second, the restoration of proper metabo- 
lism, the abnormal condition of which is shown by 
the various derangements of the bodily functions 
which are a part of the clinical picture. 

Frequently very little can be done to remove the 
cause of a fever, as this is self-limiting and its results 
impossible of abortion or shortening; still, unless 
there exist some contraindication, we may be able 
to lessen the effects of this cause by inducing elim- 
ination through various channels. This may be done 
by causing emesis and free movements of the bowels, 
increasing the quantity of urine, and stimulating the 
action of the skin so as to induce free sweating, or 
by rectal irrigation. The poison circulating in the 
blood may be rendered less harmful by the introduc- 
tion of warm salt solution (0.7%) under the skin or 

32 



GENERAL TREATMENT: DIET. 33 

directly into the blood stream through an opening into 
a vein. 

By emesis irritating substances will be removed 
from the stomach, and further infection by this route 
prevented, and the absorption of poisons through the 
stomach wall will be stopped. Free purgation will act 
in like manner upon the intestinal tract and also per- 
haps aid in removing toxic substances from the blood. 
The induction of increased action of the skin and 
kidneys leads to a like effect, and the high rectal irri- 
gations and the injection of salt solution under the 
skin, or directly into the circulation, not only dilute the 
poisons, but tend to hasten their elimination through 
the various channels and act as stimulants of con- 
siderable power upon the weakened system. 

By these means we may in exceptional instances re- 
move the primary cause of the disease; when this is 
impossible we may lessen the severity of the process 
and accomplish much toward the restoration of normal 
metabolism and the correction of the disturbed body 
functions. 

In the less severe febrile diseases the abnormal tem- 
perature, which may run from ioi° F. (38.3 C.) in 
the morning to 103 F. (39.4 C.) in the afternoon, 
needs no special attention. When high temperature 
persists and is of itself manifestly a menace to the 
patient, measures must be taken to mitigate it. This 
may be done : 

(a) By drugs. The various so-called antipyretics, 
acetphenetidin (phenacetin) , acetanilide, antipyrine, 



34 FEVER NURSING. 

etc., may be employed, but their use may be attended 
by bad effects, especially upon the heart, and their 
administration for this purpose is fast passing out 
of vogue. Patients to whom these drugs are given 
must be carefully watched by the nurse for signs of 
heart-weakness. The fall of temperature following 
their use may be accompanied by various signs of 
prostration which will necessitate warm covering, the 
use of hot-water bottles, and perhaps the administra- 
tion of whiskey, aromatic spirit of ammonia, or other 
stimulant. Consequently the reduction of fever by 
drugging is to be attempted with the greatest care, 
if at all. 

(b) Much more advisable is the control of high 
temperature by means of cold applied externally. 
This may be done in various ways as follows: 

i. The Cool Tub Bath. — To give this bath it is nec- 
essary to have two, or, if possible, three attendants. 
Have ready the following articles: a portable tub, 
a large rubber sheet, two rubber aprons, one large 
sheet, one draw sheet, a T binder or triangular band- 
age, a bath thermometer, a dish containing ice, a large 
pitcher filled with very hot water, a rubber cap to 
cover the patient's hair, non-absorbent cotton for the 
ears, two or more hot-water bottles with two covers 
for each bottle, a foot-tub for the soiled or wet linen, 
a strip of canvas or an air cushion to support the 
patient's head while in the tub, two compresses for the 
head, towels, a rectal thermometer, vaseline, safety 
pins, a bottle of whiskey, a medicine glass and drink- 



GENERAL TREATMENT: DIET. 35 

ing tube, a clock or watch placed on the table, mouth 
swabs and mouth wash, a pus-basin containing dis- 
infectant, and a glass for hot milk, which should be 
heating while the bath is being given. 

Place everthing in the most convenient place. Wheel 
the tub, which has been half filled with water at a tem- 
perature of 85 F. (29.4 C), or other proper tem- 
perature, to the patient's bedside. If the water is too 
hot, add pieces of ice wrapped in gauze; if too cold, 
add some of the hot water. Give whiskey (if ordered). 
The nurses should then roll up their sleeves to above 
the elbows, put on the rubber aprons, and proceed as 
follows :* Cover the patient's hair with the rubber cap, 
fill her ears with the cotton, and pin the triangular 
bandage or T binder around the abdomen and buttocks. 
Remove the pillow, and slip the draw sheet under the 
bed clothes over the patient, plait the bedding to the 
foot of the bed, remove the night gown and hang it 
over the bed-post, draw the patient to the edge of the 
bed near the tub, and put the cold compresses on her 
head. Lift the patient gently, instructing her to hold 
herself stiff. One person takes the head and shoulders, 
with the head resting on her (the nurse's) arm, another, 
the feet, and the third, reaching across the tub, passes 
her hands under the buttocks, at the same time keep- 
ing the draw sheet from touching the water. Begin 
rubbing the patient when she reaches the water, com- 

*The directions here given apply to the bath for female 
patients, as in their case special care must be taken that the 
hair does not get wet. With this exception the bath for 
male patients is conducted in precisely the same way. 



36 FEVER NURSING. 

mencing with the spine and extremities, and avoiding 
the abdomen. Change the ice compresses frequently, 
watch the pulse and color of the skin. The bath lasts 
from ten to fifteen minutes as ordered, and fresh 
water is used for every bath. 

Prepare the bed for the reception of the patient in 
the following manner: Have the third person cover 
the entire bed with the rubber sheet, fold the large 
cotton sheet lengthwise across the bed, and place the 
hot-water bottles at the foot, under the rubber sheet. 
Throw the draw sheet over the tub, then remove the 
binder, rubber cap, and cotton from the ears. Lift 
the patient gently into the large sheet on the bed, 
dry her by rubbing over the sheet, place the hot-water 
bottles to the feet, remove the wet sheets and rubber 
by rolling the patient from one side to the other, and 
at the same time pull up the dry bed clothes, which 
have been folded at the foot of the bed. Replace the 
night gown, fold a towel under the patient's chin, 
wash mouth, tongue and teeth with mouth-wash, and 
give hot milk to drink. Place the rubber sheet and the 
wet and soiled linen in the foot tub, ready to be disin- 
fected and hung up to dry, so that they may be used 
when the next tub is given. 

If the patient shows signs of poor reaction while 
in the bath, such as blueness of the lips and extrem- 
ities or decided shivering, or if the effect upon the 
heart is untoward, the duration of the bath should 
be lessened. In most patients chattering of the teeth 
may be disregarded, and cyanosis of the extremities 



GENERAL TREATMENT: DIET. 37 

alone need not be considered sufficient reason for 
stopping the bath; but if marked blueness of the face, 
especially about the nose, is noticed, the patient should 
be immediately taken from the water. The patient's 
temperature is useful as an indication of the effect 
and for the necessity of a repetition of the procedure. 
It is a great mistake to endeavor to lower the pyrexia 
as much as possible. Before the patient is put into the 
bath, and after removal from it, it is usual to admin- 
ister a glass of wine, a half-ounce of whiskey, a half 
to one drachm of the aromatic spirit of ammonia, 
diluted, or a small cup of hot milk or coffee, as the 
physician may direct. During the bath a glass of cold 
water may be allowed. 

The patient's powers of reaction may be measured 
by a tentative bath lasting five minutes at 90 , reduced 
to 8o° F. (32°-27° C), and the initial temperature, 
the reduction, and the length of the following bath 
may be determined accordingly. If possible, the physi- 
cian should be present during the bath, both to guard 
against the possibility of shock and to make sure that 
the good effects of the procedure are not lessened by 
too early termination of the bath. 

If the cold tub is not well borne by the patient, 
luke-warm baths, given in the same manner, are often 
followed by good results. The procedure may bring 
about a drop in temperature of from one to four de- 
grees (F.), but it is wise not to allow a reduction of 
more than two degrees (F.) (one degree C). 

In private practice an ordinary tin bath-tub from 



3» FEVER NURSING. 

five to six feet long, which may be purchased at the 
plumber's, is convenient. The stationary bath-tub, for 
obvious reasons, should never be used. In hospitals 
portable tubs are usually provided. 

The preparation of the bed for the reception of the 
patient is of the utmost importance. All should be 
ready before the beginning of the procedure, so that 
there may be no delay if it becomes necessary to termi- 
nate the bath sooner than was expected. The lower- 
ing of the temperature is not the only good effect 
produced by this measure; it is also believed to be a 
stimulant to the nervous and circulatory systems. 

2. The Bed or Slush Bath. — This is a less severe 
method than the tub bath, and many patients to whom 
the cold bath is almost unendurable bear it well and 
are very favorably affected by it. It is given upon a 
bed upon which has been placed, under the patient and 
over the pillows, a large rubber sheet, reaching almost 
to the floor at the foot of the bed, and covered with 
a muslin draw sheet. Blankets rolled lengthwise are 
placed under the rubber sheet on each side, close to the 
patient, meeting at the feet. The pillows form the 
upper end of the trough. Several pails of water are 
poured into this trough and kept cooled to the proper 
temperature by pieces of ice wrapped in gauze. The 
patient is treated just as when the tub bath is employed. 
When the bath has been given the water is drawn 
off by raising the head of the bed, separating the rolls 
of blankets at the feet, and allowing the water to run 
into a tub, which has been placed on the floor at the 



GENERAL TREATMENT: DIET. 39 

foot of the bed. A dry sheet is thrown over the patient 
and the rolls of blankets are removed. The patient 
is dried and the wet rubber and sheets removed in the 
same manner as when the tub bath is given. The 
after-treatment is the same. The bed bath may be con- 
structed also by passing a piece of clothes-line around 
the head and foot of the bed, connecting these by two 
parallel ropes, and throwing over the whole an oil cloth 
which is attached to the rope by clothes-pins ; or a rec- 
tangular fence about eight inches in height and slightly 
smaller than the mattress may be constructed, over 
which a rubber sheet may be thrown. The water from 
these improvised tubs may be drawn off by a siphon 
made of a few feet of rubber hose. 

3. The Sponge Bath. — For this measure the water 
may be of various temperatures, as indicated; often 
the addition to it of a little alcohol is very grateful 
to the patient. For the sponge bath the following 
articles will be required: two head compresses in a 
glass dish of ice water, two large compresses for the 
chest and abdomen, two large compresses for spong- 
ing, a large rubber to cover the entire bed, two 
foot-tubs and ice, one draw sheet, one large sheet, hot- 
water bags with covers, alcohol (50%), thermometer, 
whiskey and hot milk (if ordered). Plait the large 
rubber and large sheet together, slip the draw sheet 
under the bed clothes, covering the patient, and fold 
the bed clothes at the foot of the bed. Remove the 
night-garment, roll the patient on the right side, and lay 
the folded rubber and large sheet on the bed, close to 



40 FEVER NURSING. 

him. Turn the patient over and draw the sheets smooth 
under him. Place cold compresses on the head, chest and 
abdomen. Bathe the face with ice water, and sponge 
the arms and legs for two minutes each, the chest for 
two minutes, and the back for five minutes. In spong- 
ing the arm the sponge is carried down along its inner 
surface to the hand ; after which the sponge is turned 
over and passed up on the outside of the arm. Change 
the compress after each stroking. Sponge the leg from 
the groin to the ankle and up along the outside. 
Change the compresses on the head, chest and abdomen 
every three minutes. Roll the patient on his side and 
bathe the back for five minutes. Dry the back with 
the sheet and roll the wet sheet of rubber close to the 
patient's back. Remove the compresses and roll the 
patient over on his other side, on the dry bed. Re- 
move the wet clothes and rubber, and put them in 
a foot-tub. Draw up the bed clothes and apply the hot- 
water bottles to the patient's feet. Replace the night- 
dress, wash the mouth, and give a hot drink. The 
same sheets and compresses may be dried for the next 
treatment. Care must be taken to keep the portions 
of the body which are not being sponged covered. 
Particular attention should be given the back, for here 
the tissues retain the heat longest. Proper reaction 
is evidenced by redness of the skin. No such effect 
is produced upon the temperature by sponging as by 
tubbing; nevertheless the fever may be slightly low- 
ered. The chief good accomplished is its favorable 
action upon the skin and the great comfort which it 
affords the patient. 



GENERAL TREATMENT: DIET. 4* 

4. The Sprinkle Bath. — As a method for the reduc- 
tion of temperature this may be considered as rivalling 
the tub bath. It has the advantage of being better 
borne by many patients and of peculiar adaptation to 
private practice. The technique is as follows: The 
head of the bed should be raised about ten inches from 
the floor, and, to keep the mattress from sagging, 
under it should be placed crosswise several pine boards 
as long as the width of the bed. The mattress should 
be covered with a rubber sheet, under which rolls of 
blankets have been placed to form a trough. The 
patient should be stripped and sprinkled with water 
of the desired temperature from an ordinary watering- 
pot or from an irrigating apparatus to the tube of 
which a sprinkling-nozzle is attached. The water, as 
it flows from the foot of the bed, should be received 
in a large dish-pan or foot-bath, and can be used over 
and over; the proper temperature being maintained 
by the addition of ice. The water should not be 
poured from too great a height, and should be applied 
chiefly to the abdomen and legs. Rubbing with the 
hands should be kept up throughout the procedure, 
and otherwise the patient should be dealt with exactly 
as in tub bathing. 

5. The Sheet Bath. — A sheet wet with water at 
8o° F. (2J C.) is placed upon blankets on a bed or 
table, and the patient, with arms raised above his head, 
is tightly wrapped in it. Water is now poured upon 
the successive parts of the body, which are rubbed 
with the hand until warm, and then cooled by means 



42 FEVER NURSING. 

of colder water. When an area ceases to become 
warm, another part is attacked in like manner, and so 
on until the whole body has been subjected to the 
procedure. 

6. The Towel Bath. — The patient being undressed 
and laid upon a blanket or muslin sheet under which 
a large rubber sheet has been placed, a thoroughly 
wet towel is placed smoothly over the back; rubbing 
is employed over this until it becomes warm. Then 
water is poured over the surface till it cools, friction 
is again employed, and the process repeated till the 
warmth ceases to return. The buttocks are next 
treated in like manner, and the back having been dried, 
the anterior surface receives the same treatment. 

7. The Ice Rub. — This consists simply in rubbing 
the surface of the body with flat pieces of ice covered 
with gauze. The various parts of the body are treated 
one after another until they are cooled. The patient 
is then dried and properly covered. In excessively 
high temperatures the ice rub may be employed while 
the patient is in a tub bath. 

8. The Ice Pack. — The patient, having been stripped, 
is laid upon a bed covered with a rubber sheet. An ice 
cap is applied to his head. Flat pieces of ice are ar- 
ranged along the sides of the body, in the armpits and 
between the legs, and the body is rubbed with pieces of 
ice just as in the ice rub. The ice may be in direct 
contact with the skin or, better, wet cloths may be 
interposed. 



GENERAL TREATMENT: DIET. 43 

9. Ice Bags, Compresses and Coils. — Ice bags are 
frequently used for the local application of cold. 
These are rubber bags of various shapes and sizes, 
being adapted in these respects to the portions of the 
body to which they are to be applied, and are fitted 
with screw caps. When in use they should be about 
three-quarters filled with ice broken into pieces the 
size of the end of the thumb. As little air as possible 
should be allowed in the bag. 

Ice compresses are made by crushing the ice and 
spreading a layer of it between two folds of blanket 
or towel, preferably the latter, as it will absorb the 
meltings while the former will not. These compresses 
may be made of considerable size and applied over 
large areas, but their use has the extreme disadvantage 
that it is almost impossible during their employment 
to keep the bed and clothing dry. 

Cold compresses, while they do not affect the tem- 
perature, often give the patient great comfort, espe- 
cially when applied to local areas of pain. They are 
made of several layers of any fabric which will absorb 
and hold moisture, and are wrung out of water at the 
required temperature and applied. They may be re- 
newed as often as is necessary, and it is well to have 
two in use at the same time ; or they may be allowed 
to remain in contact with the patient's body continu- 
ously, the water lost by evaporation being supplied 
from time to time. 

Ice coils of rubber tubing, arranged in various 
shapes to fit the different parts of the body, are often 



44 FEVER NURSING. 

used to reduce the heat of local inflammation. Water 
at the proper temperature is caused to run through 
the tubing by siphonage, the vessel from which it runs 
being placed above the patient and that into which it 
is discharged on the floor. Care should be taken that 
the former does not become exhausted. An ice coil 
may be made at home from ordinary flexible rubber 
tubing, laced together with narrow tape, and about 
twelve yards of tubing are required for the purpose. 
It may be coiled into circular, oval or rectangular 
form, depending upon the part to which the application 
is to be made. At each extremity of the tubing from 
four to six feet should be left free. 

10. Ice-water Enemata. — These often cause a con- 
siderable fall in temperature, reaching as they do to 
the " heat-citadel " of the body. Hare has found that 
enemata of 65 F. (18.3 C.) lowered the body tem- 
perature 3 F. (1.5 C.) in thirty minutes. They 
should be given with a fountain syringe; never with 
a Davidson syringe, as the bowel has been ruptured 
by this instrument, owing to the sudden increase of 
pressure attendant upon squeezing the bulb. Two 
soft rectal tubes (one large, one small), after the air 
has been expelled, are well lubricated and passed up 
into the bowel; the large tube for a distance of 
about six inches, and the small tube about ten inches. 
The large tube must reach to a jar on the floor beside 
the bed, and the small one connects with the fountain 
syringe. In the place of the two catheters thus in- 
serted, some pieces of rubber tubing may be attached 



GENERAL TREATMENT: DIET. 45 

to a Kemp's tube, which is inserted into the rectum. 
The usual quantity of water injected is from one to 
two quarts, a return flow being allowed as the fluid 
passes in. 

In using any of the above methods for the reduction 
of temperature the greatest watchfulness of the pa- 
tient's condition should be observed, and any tendency 
to collapse, as evidenced by distress, weakening of the 
pulse, coldness of the extremities, and blueness of the 
lips, should cause the nurse to notify the physician 
immediately and to institute prompt restorative meas- 
ures, such as the administration of whiskey, brandy or 
the aromatic spirit of ammonia, rubbing the hands and 
feet, hot-water bottles to the extremities and over the 
heart, and elevation of the foot of the bed. 

If hyperpyrexia occur in the absence of the physi- 
cian, it is the duty of the nurse to meet the emergency 
by the application of cold compresses and by cold 
sponging, in the meantime preparing for an ice-water 
enema and cold tub bath pending the arrival of the 
medical attendant. 

The Treatment of Symptoms Referable to the 
Skin. — At the onset of a febrile disease it is often wise 
to induce free perspiration by the use of hot-water 
bottles, blankets, etc. During the course of the illness 
the patient's skin should be kept clean by a daily bath 
with warm water and soap. Dryness and harshness of 
the skin may be relieved by anointing the body with 
albolene or olive oil. Scales and pieces of epidermis 
that are cast off during and after contagious fevers 



46 FEVER NURSING. 

should always be destroyed, preferably by burning, as 
they may become sources of further infection. Special 
attention should be given the points where bed-sores 
are likely to form, namely the backs of the heels and 
over the buttocks and sacrum. The sheets must be 
kept smooth, and the bed thoroughly clean and free 
from crumbs, moisture and contamination from the 
discharges from the rectum and bladder. The chief 
consideration is to prevent the beginning of bed-sores 
by the strictest cleanliness ; in addition to which meas- 
ures to improve and harden the skin of the susceptible 
parts should be employed. To insure a good blood 
supply to these parts the patient should be turned upon 
his side several times a day, and the skin of the back 
thoroughly rubbed with a dry towel and dusted with 
talcum powder. Applications rubbed into the skin to 
harden it, such as salt, two drachms, to whiskey, one 
pint, or a dilute solution of lead subacetate may be 
employed. When the skin becomes red and irritated, 
dry powder sprinkled on a compress and held in place 
by strips of adhesive plaster may be used. If the 
skin is still unbroken, it should be painted with a 
solution of silver nitrate, twenty grains to one ounce 
of water. When a bed-sore has appeared, the patient, 
with the object of preventing its spread and of accel- 
erating its cure, must be so placed as to take all weight 
from the affected part. This may be accomplished by 
the use of an inflatable rubber bed-ring. The sore 
itself must be kept clean by being swabbed with I to 
5000 mercury bichloride solution, and dusted with 



GENERAL TREATMENT: DIET. 47 

iodoform powder. A dressing of gauze on which zinc 
oxide ointment has been spread should also be applied. 
In advanced cases the use of the water-bed may become 
necessary. If the sore spreads and burrows into the 
surrounding parts, free opening and thorough irriga- 
tion are indicated. 

The Treatment of Symptoms Referable to the 
Mucous Membranes. — Dry and cracked lips may be 
made more comfortable by gentle rubbing with albo- 
lene or cold cream. For the immediate relief of thirst, 
water, cracked ice, and acidulated drinks may be given 
as often as desired ; a drink consisting of glycerin, one 
drachm, boric acid, half a drachm, to the tumblerful of 
water, may be found acceptable. The mouth should 
be kept sweet and clean by the employment of regular 
and frequent washings with dilute antiseptic solution 
(the official liquor antisepticus) , tincture of myrrh, etc. 
The following are serviceable mouth- washes : Tincture 
of myrrh, one ounce, sodium bicarbonate, ten grains, 
water, four ounces; glycerin and lemon juice, equal 
parts; Dobell's solution. A veiy useful formula con- 
sists of equal parts of antiseptic solution, hydrogen 
dioxide solution, lime water, and water. The nurse 
should be careful to see that the mouth is washed after 
each drink of milk. There is no contra-indication to 
the use of the tooth brush. Sordes and coatings upon 
the tongue may be removed by swabs moistened in one 
of the above-mentioned solutions. A convenient 
tongue-scraper may be made of a piece of whale-bone 
bent into a loop. In cases where the tongue is ex- 



48 FEVER NURSING. 

tremely dry, the "tongue-bath" often affords much 
relief. This consists simply in holding the mouth full 
of fluid for several moments. In this way consider- 
able moisture is absorbed by the mucous membrane. 

The Treatment of Symptoms Referable to the 
Digestive Organs. — The nausea and vomiting may be 
relieved by restriction of diet and by the administra- 
tion of cracked ice. All vomited matter should be 
carefully inspected by the nurse, and if it is unusual 
in appearance should be kept for examination by the 
physician. Excessive distention of the stomach or 
bowels by gas may be relieved by the application of 
hot compresses or by turpentine stupes made and 
applied by the following method : Required are a stupe 
wringer made of coarse dishtoweling, with a hem on 
each end through which are passed two smooth, round 
sticks, such as pieces of broom-handle, a large piece 
of flannel, a large layer of non-absorbent cotton, two 
pieces of flannel for stupes, a saucepan, an alcohol 
lamp, a fork or spoon, turpentine, hot water, and 
a medicine glass. Place the saucepan, containing one 
pint of boiling water and one drachm of turpentine, 
over the alcohol lamp ; put the two stupes in the water ; 
lift one of the stupes from the water into the stupe 
wringer with the fork, leaving the other in the water 
while the first is being applied ; wring very dry, shake 
out to allow the air to touch all parts of the flannel, 
and apply hot; cover with the cotton. Change the 
stupes before they become cold, having the hot one 
ready to apply when the cold one is removed. When 



GENERAL TREATMENT: DIET. 49 

the stupes are discontinued, dry the parts well, dust 
with talcum powder, and cover with the piece of warm, 
dry flannel. If marked redness and irritation are 
caused, the stupe should be at once removed and the 
skin anointed with albolene or olive oil. In many in- 
stances gaseous distention may be relieved by the 
insertion of a rectal tube through which the gas es- 
capes, and perhaps even better than this is the admin- 
istration of a high rectal irrigation of a warm salt 
solution (one drachm to the pint). 

At the beginning of a fever the bowels should be 
opened by repeated small doses of calomel (one-tenth 
to one-fourth of a grain every half-hour up to six 
doses), followed by a saline, such as Rochelle salt 
or solution of magnesium citrate. During the course 
of the disease a daily movement of the bowels should 
be secured by this means, by other laxatives, or by 
enemata of warm soapsuds. 

Diarrhoea occurs more especially in enteric fever and 
measles. This may be relieved by a mustard plaster 
to the abdomen (not in eruptive diseases), by flushing 
out the lower bowels with a warm saline solution, or 
by the injection into the rectum of from one to ten 
drops of laudanum in an ounce of starch mucilage. 

The Treatment of Symptoms Referable to the 
Circulatory System. — The pulse in fever should be 
studiously watched by the nurse, and any marked 
change in its character reported at once to the physi- 
cian, since by noting its action a fairly reliable estimate 
of the patient's general condition can usually be made. 
5 



50 FEVER NURSING. 

In severe cases heart-weakness may call for stimu- 
lants such as whiskey. In extreme cases this may 
be administered hypodermatically, and in case of col- 
lapse hypodermatic injections of camphor and ether or 
camphor and olive oil may be given, when directed by 
the physician, with good effect. 

The Treatment of Symptoms Referable to the 
Respiratory System. — The dry, irritating cough 
caused by tickling in the throat may often be relieved 
by a drink of water or milk or by the employment of 
a simple jujube troche or gum drop, or of gomenol 
bonbons. Various expectorant and sedative drugs are 
used in the cough which accompanies involvement of 
the lungs. If the cough is so frequent and severe as 
to cause soreness of the chest, this may be lessened by 
the application of hot compresses or by rubbing with 
various liniments which may be prescribed by the 
physician. 

The Treatment of Symptoms Referable to the 
Urinary System. — The urine should be carefully ex- 
amined by the nurse as to color and sediment, and its 
daily quantity noted; when directed she should save 
bottled and labeled specimens for the physician. Such 
a specimen to be of any diagnostic value should be a 
portion of the mixed urine of an entire twenty-four 
hours. In cases of diabetes, separate specimens of the 
urines of fasting and of digestion should be kept. 
Four ounces are, as a rule, a sufficient quantity; it is 
important that the bottle should be clean. Freer action 
of the kidneys may be secured, and the urine rendered 



GENERAL TREATMENT: DIET. 5* 

less irritating, by the administration of a saline diu- 
retic, preferably perhaps in the form of "cream of 
tartar (potassium bitartrate) lemonade." This is pre- 
pared by dissolving one and one-half drachms of 
cream of tartar in a pint of boiling water. Allow it 
to cool, flavor with a little lemon juice or peel, add a 
little ice, and sweeten with sugar. This is a very 
palatable drink and may be taken ad libitum. When 
the urine is much diminished in quantity, or retention 
(a rare occurrence) is present, an increased flow of 
urine may be induced by hot applications over the 
kidneys or a high rectal irrigation of hot salt solution. 
In certain infectious diseases, notably typhoid fever, 
the urine is capable of transmitting the infection ; con- 
sequently it should be handled with the greatest care 
and disinfected properly before being disposed of {see 

P. 79). 

Seeming retention of the urine may be treated as 
above. Nervous patients who experience difficulty in 
voiding urine while in the recumbent position may be 
aided in starting the flow by the sound of running 
water or by having warm water poured over the pubes. 
When obstinate retention occurs and the patient is 
entirely unable to void the urine, catheterization must 
be practiced. This may be done by the nurse upon 
the physician's order. Soft-rubber catheters are pref- 
erable for males and glass instruments for females. 
The greatest care is necessary to keep these absolutely 
clean, for unless this is done infection may be carried 
into the bladder, and cystitis result. Such an accident 



52 FEVER NURSING. 

should never happen, and when it does is due to care- 
lessness in the care of the catheters, lack of cleanliness 
of the hands of the person who performs the opera- 
tion, or faulty technique in cleansing the patient's ure- 
thral orifice. Catheters should be boiled after using, 
and kept in a i to 5000 solution of mercury bichloride. 

To catheterize a female patient the following articles 
will be required : a large sheet, a chest blanket, a small 
bed rubber, sterile towels, a drop light, two curved 
basins, two or more sterilized glass catheters, two 
dishes which have been sterilized by soaking in a 
1 to 1000 solution of mercury bichloride, and sterile 
cotton balls. These having been conveniently arranged, 
proceed as follows : 

Fill one dish with mercury bichloride, 1 to 5000, 
and put into this about six cotton balls ; fill the other 
dish with boric acid solution, 4%, and into this dish 
place the catheters, previously boiled. The nurse should 
then screen the patient, drape her with the large sheet, 
in the dorsal position, and place a sterile towel and the 
rubber under her, and the dishes and curved basins on 
the bed ; covering the latter with a sterile towel while 
she (the nurse) prepares her hands. These should be 
scrubbed well with green soap and running water, and 
then soaked in the mercury bichloride solution. Sepa- 
rate the labia and wash off the parts with the mercuric 
bichloride solution. Insert the catheter very gently 
into the urethra, being careful not to use force or 
touch any other part with the instrument. When the 
urine ceases to flow, place one finger over the end of 



GENERAL TREATMENT: DIET. 53 

the catheter and withdraw it. It is wise to attach 
about a foot of rubber tubing to the open end of the 
glass catheter, in order to guard against its passing 
wholly into the bladder, and also to lessen the chances 
of soiling the bed-clothes with urine. When inconti- 
nence exists, a soft-rubber urinal may be useful. 

The Treatment of Symptoms Referable to the 
Nervous System. — The discomfort of the initial chill 
{rigor) of febrile disease may be relieved by warm 
covering, by hot-water bottles to the extremities, by 
rubbing the body and limbs with warm woollen cloths, 
and by the administration of hot stimulant drinks. 
One drachm of aromatic spirit of ammonia in half a 
glass of hot water is usually effective. These meas- 
ures are also applicable to the relief of chills occurring 
during the course of the disease. In children, convul- 
sions may be treated by hot baths or by the administra- 
tion of a few whiffs of chloroform from time to time. 
A mustard bath is very often given to children for 
convulsions. Two tablespoon fuls of mustard, tied up 
in a muslin bag, are used to the gallon of water at a 
temperature of 112 to 115 F. (44.4 to 46.1 ° C). 
Before placing the child in the bath apply an ice com- 
press to its head, and change this at intervals during 
the bath. The pulse must be carefully watched while 
the child is in the bath. The passage of a stomach 
tube and the washing out of the organ, or a rectal irri- 
gation of warm saline solution, will frequently cause a 
cessation of the convulsions. 

During convulsions in the course of febrile disease 



54 FEVER NURSING. 

the nurse must take care that the patient does himself 
no injury; beyond this the less he is restrained the 
better. Constricting clothing about neck or chest should 
be loosened to guard against interference with respi- 
ration. If there be movement of the lower jaw, some 
object such as a spool or roller bandage should be 
placed between the teeth, to prevent biting of the 
tongue. 

The nurse by her manner can do much to lessen the 
irritability and discomfort of ordinary febrile disease. 
She should step quietly, talk little, notice everything, 
and, while not seeming officious in the least degree, 
anticipate every wish of the patient. 

Headache may be lessened by cold or hot compresses 
to the seat of pain. Sometimes the cold will prove 
more efficacious, sometimes the hot ; that which affords 
most relief should be selected. 

Pain in the back and limbs may be mitigated by 
hot- water bags, by massage, or by rubbing with various 
embrocations. Dizziness is lessened by the recumbent 
position. When arising after a continued illness the 
patient should first be allowed to sit up in bed for an 
hour or two, a day or two later he may be helped to 
an easy chair for a short time, then short excursions 
around the room may be undertaken with the help of 
the nurse; until finally sufficient strength has been 
recovered to enable him to walk alone. 

The mental symptoms are often relieved by the use 
of cold, as described above ; when they take the form 
of active delirium various sedatives may be adminis- 



GENERAL TREATMENT: DIET, 55 

tered, as the bromides. Chloral, with morphine as a 
last resort, should be given only under the authority of 
the physician. If restraint is necessary (and in ex- 
tremes of delirium the strength of several persons may 
be required to hold a vigorous patient), it is legitimate 
to use a folded sheet extending from armpits to groins, 
laid over the patient and fastened under the bed with 
strong safety pins. Restraint by means of tying the 
hands and feet to the bed posts is never necessary. 

During the marked weakness of severe febrile dis- 
eases the patient should not be allowed to move him- 
self in bed; this must be done for him by the nurse. 
While the patient is in such condition as to be unable 
to make his wants known to the attendants, the great- 
est care must be taken that he receive his nourishment 
in proper quantity and at regular intervals, and espe- 
cial watchfulness should be exercised lest the bladder 
become too full. Under these circumstances catheteri- 
zation may become necessary. If his bowels move 
involuntarily the soiled clothing should be removed at 
once, and the patient thoroughly cleansed. Such a 
patient must be watched with great care. 

Hiccough occasionally baffles all treatment. Cracked 
ice, a teaspoonful of salt and lemon juice or salt and 
vinegar, or a teaspoonful of raw whiskey, may prove 
efficacious. Obstinate cases may respond to the anti- 
spasmodic drugs or the hypodermatic use of morphine 
when ordered by the physician. In certain cases the 
use of electricity may meet with success. 

The Treatment of Symptoms Referable to the 



56 FEVER NURSING. 

Organs of Special Sense. — The care of the tongue 
has been described in the section on mucous mem- 
branes. 

The Nose. — Dryness and excoriation of the nostrils 
may be prevented by anointing these parts with albo- 
lene or olive oil, and the crusts which collect inside 
the nose may be softened and removed by swabs fash- 
ioned from toothpicks and bits of cotton and dipped in 
any of the alkaline solutions mentioned below. The 
patient should be encouraged to blow his nose, and 
additional cleanliness may be secured by the use of the 
hand-bulb atomizer filled with an alkaline spray solu- 
tion such as the official antiseptic solution diluted one 
part to four or six of water. A necessary precaution 
in this process is not to allow the patient to blow his 
nose for some moments after the use of the spray ; 
otherwise bits of the secretion may be forced into the 
Eustachian tubes, and inflammation of these and conse- 
quent middle ear disease possibly be caused. Nose-bleed 
(epistaxis) is usually controlled by elevating the head 
and shoulders of the patient, and placing ice-water 
compresses upon the forehead and root of the nose. 
A bit of absorbent cotton, wet to saturation with water 
as hot as can be borne, and inserted into each nostril, 
is usually effectual. If the haemorrhage is severe and 
exhausting the physician should be notified. 

The Ears. — The increased acuteness of hearing which 
may be present in fevers may be rendered less dis- 
tressing by insisting upon quiet in the house, and 
especially in the sick-room. A ban should be put upon 



GENERAL TREATMENT: DIET. 57 

loud conversation; attendants should speak in a low 
tone, but whispering is frequently extremely irritat- 
ing to the patient. If there be much traffic about the 
house it is often wise to cause the pavements to be 
strewn with tan bark. The patient should be fre- 
quently questioned as to the presence of pain in the 
ear, and such an occurrence should be immediately 
reported to the physician. Such pain may be relieved 
by hot applications to the organ, by poultices around 
(never over) it, or by careful syringing with warm 
water. For poultice material the official kaolin cato- 
plasm is preferable. It may become necessary to punc- 
ture the drum membrane in order to drain the tym- 
panic cavity. This should be done only by the phy- 
sician. When there is discharge from the auditory 
canal, cleanliness may be attained by syringing or by 
mopping with small cotton swabs moistened in weak 
antiseptic solution. 

The Eyes. — Increased sensitiveness to light may be 
rendered less annoying by screening the patient's bed. 
This is preferable to darkening the apartment, for sun- 
light is a sick-room necessity. At night the room 
should be dimly lighted, and the lamp so shaded that 
its rays do not fall directly upon the patient. If there 
is tendency to dryness of the eyelids, these should be 
moistened with warm boric acid solution ( full strength 
or half saturated). When there is tendency to in- 
crease of secretion and the lids stick together, the same 
agent may be used, or the edges of the lids lightly 
smeared with albolene or olive oil. The eyes should 



58 FEVER NURSING. 

not be used during the illness, and only to the slightest 
extent during convalescence. This is especially to be 
remembered in the care of cases of measles. 

Feeding in Febrile Disease. — The diet of patients 
suffering from fever must be one consisting of food 
that will be easily digested and at the same time keep 
up the nutrition of the body. All food should be given 
in liquid form and should be of such character as to 
furnish as much nourishment for its volume as pos- 
sible. 

The objects to be attained in the dietetics of fever 
are: 

(a) To supply nutriment sufficient to compensate 
for the tissue consumed. 

(6) To give nourishment which will leave as little 
undigested residue as possible and which will not dis- 
turb the weakened organs of digestion. 

In fevers with remissions of temperature it is best to 
give the largest amount of food while the temperature 
is low, for at this time the digestive and assimilative 
powers are best able to do their work. 

Milk, since it offers the greatest amount of nourish- 
ment for its volume, would seem the ideal food, but it 
has its disadvantages. Of these the most important is 
that it is likely to coagulate in the stomach in large 
curds, which cause distress and are not easily acted upon 
by the juices of digestion. This fault may be obviated 
in various ways. The milk should be administered 
slowly, so that when coagulation occurs there will be a 
number of small curds, rather than a single large one. 



GENERAL TREATMENT: DIET. 59 

By dilution with various carbonated waters, or by par- 
tial predigestion by peptonization, milk may be so 
prepared as to avoid disturbance from this cause. 
Peptonized milk may be prepared by the cold process : 
Into a clean quart bottle put pancreatin, five grains, 
and sodium bicarbonate, fifteen grains, and one tea- 
cupful of cold water; shake and add a pint of fresh 
milk ; shake the mixture again, and immediately place 
on ice. When needed, shake the bottle, pour out the 
required portion, and replace on ice. If the warm 
process is ordered, prepare as above, but set the bottle in 
hot water, though not so hot that the whole hand cannot 
be held in it without discomfort — about 115 F. (44.1 ° 
C). At the end of ten minutes place it on ice, in 
order to check further digestion and keep the milk 
from spoiling. Kumyss (milk which has undergone 
alcoholic fermentation) or matzoon (milk which has 
undergone lactic acid fermentation) are well borne by 
many patients who object to or are distressed by plain 
milk. 

After milk in nutritive value in fevers come the dif- 
ferent liquid preparations of meat — meat juice, soups, 
broths and the like. Soups and broths contain much 
less nutriment than milk, but on account of the high 
temperature at which they are usually taken, and on 
account of the salts which they contain, they possess 
certain stimulant properties which render them useful. 
Patients quickly tire of them, but by flavoring them 
with the different vegetable extracts, celery, onion, and 
the like, they may be made less monotonous. The 



60 FEVER NURSING. 

vegetable purees may be employed. These are pre- 
pared by thickening pure soups with powdered rice, 
arrowroot or flour. 

In mild cases of fever, and in those of only short 
duration with little digestive disorder, the patient may 
be allowed the various semi-solid foods, such as oat- 
meal, arrowroot or barley gruel, milk toast, meat jelly, 
soft-boiled eggs, and the like. 

Many patients insist that they cannot take milk, but 
most of these will find out their error if the nurse will 
exercise tact and gentle persuasion. It may be ren- 
dered palatable in various ways — for instance by the 
addition of half an ounce of strong coffee to each glass, 
or in the form of junket, which may be flavored with 
a little sherry or nutmeg. Matzoon, kumyss and the 
various proprietary foods, as malted milk, Mellin's 
food, etc., should be tried if milk really is impossible ; 
and if these prove distasteful we must fall back upon 
the soups and gruels above mentioned. A diet of 
vegetable gruels alone will not provide sufficient nour- 
ishment; consequently these must be supplemented by 
egg-albumin, gelatin and broths. Eggs may be allowed ; 
these are most digestible when raw or only slightly 
cooked. They may be taken beaten raw with milk, 
with or without a little brandy, or the yolk alone may 
be beaten with hot milk or water or with sweetened 
hot tea. The eggs should never be boiled, but should 
be placed in water that has been boiling, and allowed 
to stand for a quarter of an hour. This process cooks 
them slightly, and an egg thus prepared may prove 



GENERAL TREATMENT: DIET. 61 

acceptable to patients to whom the idea of a raw egg 
is unpleasant. 

Gelatin in meat, wine or fruit- juice jelly, or in the 
form of blanc-mange, which may be variously flavored, 
is often agreeable. These jellies must be given in 
connection with other foods, as they contain little 
nourishment in proportion to their volume. 

Plain ice creams, preferably flavored with vanilla, 
are allowable. The following are types of diet which 
may be varied for individual patients : 

(i) Fluid Diet: Milk, broths, bouillon, milk punch, 
eggnog, egg lemonade, egg albumin, beef juice, strained 
gruels, cocoa, cocoa shake, kumyss, matzoon, liquid 
peptonoids, lemon and wine jellies, buttermilk. 

(2) Soft Diet: Soups (without vegetables), oysters, 
all cereals, milk toast, eggs (soft or poached), milk 
puddings, ice cream, scraped beef, toast, junket, tea, 
coffee, cocoa, milk. 

(3) Diabetic Diet: Soups, ox-tail, turtle, bouillon; 
drinks, lemonade, coffee, cocoa (without sugar) ; meats 
(with discretion), fish, fowl; eggs, in every form; veg- 
etables, lettuce, tomatoes, radishes, cucumbers, spinach, 
celery ; fruits, lemons, oranges, currants ; gluten bread, 
butter, nuts. This is intended for diabetic patients 
suffering from any intercurrent febrile disease. 

Beverages in Febrile Disease. — In all fevers the 
liberal use of water, either plain or flavored with lemon 
juice, is necessary. It not only mitigates the thirst but 
acts as a diuretic and aids in "flushing" the system, 
through the kidneys. Patients in the later stages of 



62 FEVER NURSING. 

fevers who are unable to ask for it should be regularly 
given water in sufficient quantities by the nurse. 
Lemonade, if preferable to water, should be not too 
sweet, and, if the patient desires, may be made with 
any of the carbonated waters. The juice of squeezed 
fruit, strained and either clear or diluted with water, 
is often well-borne. It contains some nutriment, and 
is slightly laxative. Barley or oatmeal water, plain 
or sweetened and flavored with fruit juices, is often 
palatable. In the milder fevers tea or coffee once a 
day will do no harm, but when there is difficulty in 
sleeping, nervousness or indigestion these should be 
interdicted. 

The nurse should remember that thirst is much more 
thoroughly assuaged by sipping than by taking con- 
siderable quantities at one time. The patient may be 
allowed to choose the temperature of his beverage, for 
he is much more likely to take the necessary quantity 
of fluid if this privilege be granted. Too much cold 
liquid in the stomach may cause cramps, and these may 
be avoided by giving only small quantities at a time. 

Diet in Convalescence. — Patients who have passed 
through a protracted and severe illness should exercise 
great care in coming back to ordinary diet, for any 
alimentary disturbance may cause a rise in tempera- 
ture and other untoward symptoms; consequently the 
return to solid diet should be gradual. 

Often the first solid food allowed is a sandwich of 
dry toast or zwieback and scraped beef or minced 
chicken; later the variety may be increased by the 



GENERAL TREATMENT: DIET. 63 

addition of soups thickened with rice, barley, plasmon, 
vermicelli or noodles. The various cereals, plain cus- 
tards, and stewed fruits may be added in quick suc- 
cession. 

Below is given a diet list for convalescents from 
ordinary febrile diseases. Such a list must be greatly 
modified for typhoid fever patients or those who have 
suffered from other fevers which especially affect the 
digestive system. 

First Day. 
Breakfast. — Soft-boiled egg, zwieback, cocoa. 
Luncheon. — Eggnog. 

Dinner. — Bit of breast of chicken, slice of dry toast. 
Luncheon. — Cup of hot bouillon. 
Supper. — Scraped beef sandwich, lemon jelly, glass 
of milk. 

Second Day. 
Breakfast. — Poached egg on toast, cocoa. 
Luncheon. — Cup of junket. 

Dinner. — Puree of potato soup, crackers or zwie~ 
back, rice pudding with cream. 
Luncheon. — Milk punch. 
Supper. — Milk toast, wine jelly, cup of tea. 

Third Day. 

Breakfast. — Egg omelette, roll, coffee with cream 
and sugar. 
Luncheon. — Hot beef broth. 



64 FEVER NURSING. 

Dinner. — Lamb broth with rice, bread and butter, a 
little vanilla ice cream. 

Luncheon. — Cup custard. 

Supper. — Half dozen raw oysters, crackers, junket, 
cup of tea. 

Fourth Day. 

Breakfast. — Baked apple with cream, oatmeal or 
other cereal with cream and sugar, soft egg, dry toast, 
coffee. 

Luncheon. — Chicken broth. 

Dinner. — Puree of celery soup, crackers, broiled 
lamb chop, mashed potato, wine jelly. 

Luncheon. — Cup of junket. 

Supper. — Scrambled eggs, dry toast. 

Fifth Day. 

Breakfast. — Orange, cereal with cream and sugar, 
coffee or cocoa, roll and butter, poached egg on toast. 

Dinner. — Half dozen raw oysters, consomme with 
vermicelli, small piece of tenderloin steak, creamed 
potatoes, vanilla ice cream or lemon ice. 

Supper. — Creamed toast, baked apple with cream, 
cup of tea. 



CHAPTER IV. 

GENERAL DIRECTIONS: DISINFECTION. 

The Nurse: The Sick-room and its Furniture: The Patient: 
Quarantine : Disinfection. 

The Nurse should go to her patient provided with 
her usual outfit, a description of which is unnecessary ; 
she should be cleanly in person and attire, observant 
and tactful. Before commencing any procedure she 
should provide herself with all appliances, substances 
and apparatus needed for it, and bestow them in con- 
venient places, so that its progress may not be inter- 
rupted. She should not, under any circumstances, 
converse, with either the patient or members of his 
family, upon other cases of like disease which she has 
cared for, and above all, she should not, no matter 
what she may think, criticise the attending physician's 
administration of the case. 

The Sick-room. — From the standpoint of the nurse 
the following are important : A model sick-room should 
be situated as far remote as possible from the noises 
and odors of the house and of the street, and be near 
to the bath-room. It should, if possible, have two 
windows on different sides of the room and a fire- 
place. The room should be large, clean, light and 
airy, with a southwest exposure. The walls should be 
painted some neutral tint. If the disease is not con- 
tagious, pictures on the walls serve to break the monot- 
6 65 



66 FEVER NURSING. 

ony of the sick-room. If curtains are used, they should 
be of light washable material, and should be frequently 
washed. Rugs may be used if small enough to be re- 
moved, shaken and aired daily. Unnecessary furniture 
and draperies should be removed. If possible, there 
should be a closet or dressing-room adjoining, where 
all utensils, medicines, etc., may be kept. In gen- 
eral, the apartment used by a person ill with febrile 
disease should be, if possible, at the top of the house, 
for the air here is purer than that nearer the ground. 
Since it is to be occupied during the term of illness 
by at least two persons, the patient and the nurse or 
nurses, it should be large. Every adult requires at 
least three thousand cubic feet per hour of fresh air, 
and this will necessitate a room the capacity of which 
is about six thousand feet. Such an apartment is 
approximately fourteen feet square by eleven feet 
high, or of such proportions that its cubic content is 
that of a room of these dimensions. A room of this 
size does not allow space for large pieces of furniture, 
and if it is to contain such its measurements must be 
correspondingly larger. A sufficient number of win- 
dows is necessary to insure plenty of light and proper 
ventilation, for while fever patients are more sensitive 
to sudden draughts than persons in health, fresh air is 
an all-important consideration. Too bright light in a 
sick-room is to be avoided ; nevertheless the apartment 
should be kept cheery rather than gloomy. It will 
seldom be found necessary to darken the apartment 
except in cases involving brain or eye complications. 



GENERAL DIRECTIONS: DISINFECTION. 67 

Proper shades for the windows will, when carefully 
disposed, be found to admit a sufficient degree of light. 
Ventilation in a private dwelling is usually provided by 
doors, windows and fireplaces, mechanical ventilation 
being seldom found in any except public buildings. 
Having recourse to these three means of ventilating the 
sick-room, we must contrive to arrange for sufficient 
change of air to afford proper ventilation without 
allowing draughts. The fireplace offers a fair outlet 
to vitiated air, but its chief fault is that its opening is 
near the floor, while impure air seeks the upper levels 
of the room atmosphere. An occasional fire built upon 
the hearth will increase the usefulness of this means of 
ventilation. Various appliances may be used to render 
the windows better ways of egress for impure air and 
of ingress for pure. One of the best of these is a 
piece of board four or five inches wide and as long 
as the width of the window- frame in which it is to 
be used. The window should be lowered from the 
top just far enough to admit the board, and when it 
is thus placed in position, there is between the upper 
and lower sashes a narrow space through which out- 
side air may enter. Through the board may be bored 
holes of variable number, depending upon the tempera- 
ture outside, through which the air of the room may 
make its exit. In cold weather, or when the outside 
air is smoky or dusty, the opening between the two 
sashes may be packed, with varying degrees of tight- 
ness, with cotton. The temperature of the room should 
be from 65 to 70 F. (18.4 to 21. i° C.) in cold 



68 FEVER NURSING. 

weather, and in summer as near this temperature as 
is practicable. In hot weather the blinds and windows 
should be kept partly closed during the day, and 
opened at night. An electric fan may add to the 
thoroughness of the ventilation and to the patient's 
comfort. 

There should be no hangings, pictures or carpets, 
and as little furniture as possible in the ideal sick 
chamber; this must be insisted upon in cases of con- 
tagious disease. If there be a set wash-bowl in the 
apartment, it is well to keep its outlet plugged, lest 
impure air enter through a possibly defective trap. 
The floors and walls should be bare and smooth, so 
that they may be easily cleaned and washed with dis- 
infectants if necessary. Adjoining the sick-room there 
should be a bath-room, with tub, wash-bowl and water- 
closet. All creaking doors and blinds should be oiled. 
The patient's apartment should be kept as fresh and 
cheery as possible, and cleanliness must be attained by 
daily mopping the floor with a mop dampened with a 
disinfecting solution (i to iooo mercury bichloride) 
and by wiping walls, wood work and furniture with 
cloths dampened in the same medium. If sweeping 
is absolutely necessary, the floor should first be damp- 
ened. Dry sweeping and dusting are to be absolutely 
forbidden. 

Unpleasant odors may be dispelled by sprays of 
Labarraque's solution or of cologne water, unless dis- 
agreeable to the patient. Fresh flowers may be allowed 
in the room, but when removed they should be burned. 



GENERAL DIRECTIONS: DISINFECTION. 69 

A roomy closet is a convenient and almost necessary 
adjunct ; in it may be kept various unsightly utensils, 
medicine bottles, disinfecting solutions, and the like, 
and in non-contagious cases, bed-linen, towels, etc. 

During the day the room may be kept as bright as 
the patient wishes. Should he prefer a dim light, this 
may be provided for by shading the windows and 
screening the bed. At night the lamp should be low 
and so disposed that its rays do not fall directly upon 
the patient. 

The Furniture. — The bedstead preferably should be 
of metal of plain design, and furnished with a stiff 
wire mattress. The single bed is better than the 
double, since it permits the nurse to handle the patient 
with far greater ease. The iron hospital bedstead, 
which stands about six or eight inches higher from the 
floor than the common article, is much the most con- 
venient. Four wooden blocks, each with a depression 
in its top, into which the casters fit, can be used 
to increase the height of an ordinary bedstead. The 
location of the bed should be such as to provide easy 
access to each side, out of the passage of draughts, and 
not in too bright light. 

The mattress should be thin and stuffed with hair. 
In some hospitals, instead of a mattress, a number of 
blankets, folded to the proper shape and size and placed 
directly upon the springs, are used. These make an 
excellent and comfortable bed, the great advantage of 
which is ease of disinfection. 

The sheets should be of cotton, rather than of linen, 



7o FEVER NURSING. 

and beneath the draw-sheet a piece of rubber or oil- 
cloth, to protect the mattress from discharges, should 
be placed. Folded newspapers will answer this pur- 
pose in an emergency. 

Woollen blankets afford the best bed covering, being 
warmer for their weight and more easily disinfected 
than any other. 

The other pieces of furniture in the room should be 
of plainest design and as few in number as possible. 
Two chairs (one of them a steamer-chair, perhaps, but 
neither of them rockers and both with as little uphol- 
stery as possible), two or three small tables (one of 
them a bed table — a table with its point of support at 
one side so that its top can be placed over the bed), a 
commode, a screen and a back rest, should be sufficient. 

The Patient should wear a night shirt open entirely 
down the front, to facilitate changing and physical ex- 
aminations by the physician. In the case of women 
the hair should be neatly braided in two strands, or 
if, as is very rarely considered necessary, it may be 
cropped. Severe febrile disease may be followed by 
loss of the hair ; fortunately such a loss is rarely per- 
manent. 

The nurse should assist the patient at his toilet 
morning and evening; his face and hands should be 
gently bathed with wash cloth or cotton, soap and warm 
water ; the mouth should be rinsed, and, when desirable, 
the teeth may be brushed. The hair should be neatly 
and freshly arranged, and shaving, with the permission 
of the physician, may be permitted. The patient should 



GENERAL DIRECTIONS: DISINFECTION. 7* 

be given a general cleansing bath with soap and warm 
water each day, and frequently his comfort may be 
greatly increased by an alcohol rub. If he is allowed 
to rise for urination and defecation he should be 
wrapped in a flannel dressing-gown and assisted to the 
commode, which must be placed near the bed. In 
severe cases it is always desirable that the bed-pan be 
used. Although some patients will insist upon their 
inability to use this vessel, a little tactful persuasion 
will generally convince them of their error. Should 
any accident befall during its use or that of the urinal, 
the soiled linen should be at once removed and the skin 
cleansed. 

Visitors to patients ill with febrile diseases should 
be few, and it is better to permit none at all until the 
period of convalescence has begun. The fewer the 
visitors allowed, the less will the patient be distracted 
and excited, for even if visits please him their ultimate 
effect is untoward. If no visitors are allowed, then 
there is no danger of their contracting or transmitting 
the disease if it prove contagious. In cases of recog- 
nized contagious disease visitors must be absolutely 
interdicted. If the physician, as is his right and oft- 
times his duty, forbid all visitors (even members of 
the family) entrance into the patient's presence, the 
nurse can enforce the orders without causing hard- 
feeling toward herself. 

The nurse should perform her various duties quietly 
and regularly, and, in particular, all duties directly 
affecting the patient should be transacted, if possible, 



72 FEVER NURSING 

at the same time every day; making the bed and the 
patient's toilet, and especially administering his food, 
should be done according to schedule. 

Usually the physician will call at about the same time 
each day, and, when method is the watchword of the 
sick-room, the nurse will always be prepared for his 
entrance either at the regular hour or at any other. 
Nothing is more disturbing to the entire scheme of 
sick-room administration than a visit from the med- 
ical attendant when the nurse is unprepared for the 
event. The nurse should rise at his entrance, if not 
already standing, and accompany him in his inspection 
of the apartment and patient. She should maintain a 
discreet silence, speaking only in response to questions. 
At the close of the visit, if there be anything not re- 
corded upon the chart which she wishes to report, or 
any point which she wishes elucidated, she may make 
the report or the necessary inquiries. She must always 
note the physician's orders upon paper ; on no account 
may she trust to memory for them. After his depar- 
ture these should be put among the charts and records 
of the case upon which are noted the patient's tempera- 
ture, pulse and respiration, number and character of 
stools, quantity of urine, time, quantity and character 
of feeding, medication, etc. 

No one nurse alone is able to care for a severe ill- 
ness, nor can she be expected to do night and day 
duty in a mild one; in the former contingency a 
second nurse is necessary, and in the latter a member 
of the family or a servant must give assistance. 



GENERAL DIRECTIONS: DISINFECTION. 73 

In all severe illnesses a night as well as a day nurse 
is required, each caring for the patient for twelve of 
the twenty-four hours. Seven o'clock in the morning 
and seven in the evening are convenient hours for 
changing. 

The nurse's meals should not be served in the sick- 
room for obvious reasons. 

Disinfection During and After Febrile Diseases. 
— Since it is of paramount importance in the preven- 
tion of the spread of infectious fevers that all con- 
taminated material should be properly treated, and 
proper disinfection carried out when the case is fin- 
ished, and since upon the nurse the duty of seeing that 
this is accomplished frequently devolves, it is necessary 
that she should be thoroughly conversant with the 
means and methods to these ends. 

In considering this subject it is well that a clear 
knowledge of the term " disinfectant " be insisted 
upon. Since so many substances are sold under this 
name which are far from being what they purport to 
be, it is necessary that the term should be strictly de- 
fined, and that only such substances be used in this 
important connection as are of known composition 
and efficacy. 

All authorities are agreed that a true disinfectant is 
a substance which destroys all infectious organisms 
with which it comes in direct contact, while an anti- 
septic is one which merely checks the growth and 
multiplication of such germs, not, of necessity, de- 
stroying them; and that a deodorant is a substance 



74 FEVER NURSING. 

which has the effect of neutralizing offensive odors, 
acting as a germicide or not, as the case may be. 

Steam under pressure is the most certain disinfec- 
tant, and the only one upon which we can safely rely 
for the disinfection of clothing, bedding and the like. 
Sulphur dioxide gas is an effective germicide, and it 
may be produced by burning ordinary sulphur, which 
is cheap and easily obtainable, or the sulphur candles 
specially prepared for disinfecting purposes. It must 
be remembered, however, that sulphur dioxide gas 
bleaches, and is otherwise injurious to delicate fabrics 
and gilded articles, such as picture frames. 

Formaldehyde gas is an efficient disinfectant and is 
free from certain disadvantages which sulphur dioxide 
possesses, in that it does not affect fabrics and decora- 
tions to any appreciable extent. Tablets may be pur- 
chased of the apothecary, which, when burned in a 
specially constructed lamp, generate this gas. They 
are inexpensive and easily manipulated, but give off the 
gas so slowly that an apparatus which produces the gas 
rapidly and forces it into the apartment is far prefer- 
able. Such an apparatus is, unfortunately, complicated 
and expensive, but, if available, provides, perhaps, the 
best method of securing disinfection by formaldehyde. 

It is absolutely necessary that disinfection of apart- 
ments be carried out in the absence of human beings, 
for it is quite impossible for respiration to be sustained 
in such an atmosphere as is requisite for the destruc- 
tion of germ life. All attempts at disinfection during 
the patient's illness by means of placing vessels con- 



GENERAL DIRECTIONS: DISINFECTION. 75 

taining phenol (carbolic acid) about the room, by 
burning bits of sulphur, or by spraying disinfectants 
into the air, are worse than futile, since they make 
the patient uncomfortable. Good ventilation will ac- 
complish far more as regards disinfection than all 
these means combined. 

Before leaving the sick-room, a patient who has had 
an infectious fever should be given a thorough bath 
and shampoo with soap and hot water, and then be 
sponged off with a I to 3000 solution of mercury 
bichloride, or immersed in a 1 to 5000 solution of 
bichloride bath. He then should be dressed in a clean 
night dress, and removed to another apartment, where 
he may put on other clothing. 

After a patient has left the infected room the nurse 
should wash and disinfect all utensils, dishes and 
furniture. The bed should be taken to pieces and the 
sheets and pillow covers put to soak in five per cent, 
phenol (carbolic acid) solution. The mattress and 
blankets should be spread out, in order to allow the 
fumes from the disinfectant to reach all parts. The 
bed and spring mattress should be washed and disin- 
fected with the same solution. All bureau drawers, 
closets and cupboards should be opened, to allow their 
contents to be disinfected. All cracks and crevices 
should be pasted over except around one window, 
which is to be opened first after the room has been 
fumigated. Dust from the floor and all waste should 
be placed in paper bags and sent to the furnace. 
Nothing else should be removed from the room until 



76 FEVER NURSING. 

after fumigation. If the room is to be disinfected 
from the inside, the preparations should be made in 
such a way that the nurse may strike the match the 
last thing before leaving. Before the nurse leaves the 
room she should take a thorough soap and water bath, 
wash her hair, and disinfect both body and hair with 
mercury bichloride solution, I to 3000. She should 
then envelop herself in a clean sheet and put on slippers 
which have not been used in the sick-room. As soon 
as she is outside the room the soles of the slippers 
should be washed off with a disinfectant. 

The disinfection of the sick-room and its contents 
depends largely upon the means at the disposal of the 
physician and nurse. If a steam disinfecting plant is 
at hand, the bedding, draperies and other fabrics should 
be made into bundles, wrapped in clean sheets, and 
removed for steam disinfection. By carefully carrying 
such bundles, they may be transferred to the disinfect- 
ing station with little danger. The removal of all 
unnecessary articles at the beginning of the disease 
greatly simplifies the disinfecting process. The walls, 
if painted, should be treated in the same manner as 
the wood work; if they are papered they should be 
thoroughly rubbed with pieces of non-absorbent cotton ; 
then, if practicable, the old paper should be removed 
and the walls repapered. 

After these details have been attended to, all the 
windows and the doors, with one exception, should be 
closed and sealed by pasting strips of paper with com- 
mon flour paste over all the cracks. The sealing 



GENERAL DIRECTIONS: DISINFECTION. 77 

process is important, for upon the tightness of the 
room depends, in great measure, the efficacy of the 
disinfection. If the cracks allow the escape of the 
disinfecting gas, the process is of little value. Before 
sealing the last door all draperies which have not been 
removed must be spread out, and all drawers, closet 
doors, etc., widely opened. 

Sulphur dioxide or formaldehyde gas may be used 
to disinfect the room. If the apartment is bare and 
contains little decoration, the former may be employed ; 
if the reverse is the case, the latter is to be preferred. 
In sulphur disinfection four pounds of sulphur must 
be used for each iooo cubic feet of room space. A 
simple method of generating the gas is as follows: 
Two or three bricks are laid upon the bottom of an 
ordinary wash-tub, and upon these is placed a dish- 
pan, or other metal receptacle, which is to hold the sul- 
phur. The tub should contain enough water to cover 
the bricks and the bottom of the pan, so that there 
shall be no danger of fire. For this reason the vessel 
which holds the sulphur must never be placed directly 
upon the floor. The sulphur is to be broken into small 
pieces, over which alcohol is poured and set on fire by 
touching a match to the mixture. The operator should 
stand at as great a distance as possible while applying 
the match. If enough alcohol is used, the sulphur will 
be almost entirely consumed, and it is important that 
the pan should not contain too much sulphur, as in 
that case the combustion will not be complete. On this 
account it is better to use two or more pans for the 



7 8 FEVER NURSING. 

sulphur if the room is large. To produce proper dis- 
infection it is necessary that moisture be present, and, 
if the weather is not damp, we must supply this. This 
may be done by boiling water over a gas stove or by 
pouring boiling water from one vessel into another in 
the room just before the disinfection is begun. Another 
method is to place a vessel of water a few inches above 
the burning sulphur. The sulphur should always be 
so prepared that it may be set on fire immediately after 
the moisture has been supplied. After the sulphur is 
lighted the room should be closed at once, and the door 
of exit sealed as described above. 

If formaldehyde gas is employed, it may be gener- 
ated from the tablets before mentioned or generated 
from formalin in an apparatus which sends the gas 
rapidly through a tube which may be passed into the 
keyhole of a door. The latter method is preferable, 
but less practicable, than the former. 

Whichever method is chosen, the room should re- 
main sealed for at least eight hours. Even at the end 
of this time great care must be exercised in entering 
the apartment, and in so doing it is wise to wrap the 
face in a wet towel and pass quickly to the unsealed 
window and open it, to allow the gas to escape and the 
fresh air to enter. 

Disinfection of Excreta, etc. — During the illness 
all faeces, urine, pus from abscesses, and all other dis- 
charges, should be so disposed of that any infective 
material that they may contain shall be rendered harm- 
less. All substances cast off from the body should be 



GENERAL DIRECTIONS: DISINFECTION. 79 

received into glass or porcelain vessels containing a 
considerable quantity of disinfectant. The following 
are solutions adapted to this purpose : 
i. I to iooo mercury bichloride solution. 

2. 5% phenol (carbolic acid) solution. 

3. Calcium chloride, four ounces to one gallon of 
water. This last must be prepared freshly every day. 

The ordinary disinfection of faeces in the sick-room 
by nurse or attendant is of little value. This is due to 
the facts that the solution is seldom of sufficient 
strength and that the faecal matter is not thoroughly 
mixed with the disinfectant. The faeces must be care- 
fully macerated, so that the disinfectant shall come in 
contact with every atom, and the mixture must be 
allowed to stand for several hours. It may then be 
disposed of through the water-closet or buried. Bury- 
ing undisinfected stools cannot be too strongly con- 
demned, and is a serious menace to the public health. 

The urine should be mixed with at least one-tenth 
of its volume of 1 to 1000 bichloride solution, and 
allowed to stand for ten minutes before being thrown 
out. 

Sputum should be expectorated into vessels contain- 
ing 1 to 10 phenol (carbolic acid) solution, or the 
lime solution given above. Remnants of food should 
be disinfected in like manner. Pus dressings, etc., 
should be burned. 

All bed-linen and clothing should be immersed in a 
three per cent, phenol (carbolic acid) solution im- 
mediately upon removal, and allowed to stand for at 



80 FEVER NURSING. 

least two hours before being sent to the laundry. Bi- 
chloride solution is not used now for disinfecting linen, 
as it leaves an indelible stain. 

For other purposes it is advisable for the nurse to 
make a stock solution of twenty-five per cent, mercury 
bichloride, bottle it, and label it with a table giving the 
proportion to be added to water to make solutions of 
various strengths. From this stock bottle, solutions 
may be prepared as needed. This obviates waste of 
time in dissolving tablets, and is very economical. 

The surface of the patient's body and that of the 
attendant, when soiled with discharges, should at once 
be washed with a suitable disinfecting agent (i to 
5000 bichloride) . In diseases like small-pox and scarlet 
fever sponging the patient's body once a day with this 
solution is to be advised. 

The nurse should always change her clothing and 
sterilize her hands before eating. The latter may be 
done by thorough washing with soap, hot water, and 
1 to 5000 bichloride, a nail-brush being used in the 
process. 

After death from an infectious disease the body 
should be sponged with bichloride or phenol solution, 
and, after the mouth, nostrils and anus have been 
plugged with pledgets of cotton moistened with either 
of these, it should be wrapped in a sheet saturated with 
a disinfectant, placed in a metallic or air-tight coffin, 
and buried as soon as possible. The disposal of such 
bodies by cremation is always to be preferred when 
practicable. 



GENERAL DIRECTIONS: DISINFECTION. Si 

The Disinfection of Water-closets, Drains, Sinks 
and Privies. — In the disinfection of these nothing is 
more convenient and effective than lime chloride, 
which is a mixture of various chlorine compounds, or 
milk of lime, freely used ; the latter is made by adding 
one pound of freshly slaked lime to two or three quarts 
of water. Lime chloride should be purchased in sealed 
packages only, otherwise its efficacy as a disinfectant 
is slight. Air-slaked lime is of no use as a disinfecting 
agent. 

The faecal discharges from patients suffering from 
dysentery, cholera or typhoid fever should never be 
finally disposed of without previous disinfection as de- 
scribed above. All sinks, drains, water-closets, etc., 
should be thoroughly flushed several times daily, and 
in the intervals of flushing chloride or milk of lime 
should be allowed to remain in them. The seats of 
commodes and water-closets must be immediately 
cleansed, with a disinfectant, of any discharges which 
may soil them. 



CHAPTER V. 

INFECTIONS OF CONTINUED TYPE. 

Enteric Fever: Paratyphoid Fever: Weil's Disease: Typhus 
Fever: Yellow Fever: Influenza: Malta Fever: Mountain 
Fever: Acute Miliary Tuberculosis: Chronic Pulmonary 
Tuberculosis. 

Enteric Fever. 

Synonyms. — Typhoid Fever; Nervous Fever; Ab- 
dominal Typhus. 

Definition. — A communicable fever lasting three 
to four weeks, marked by inflammation and ulceration 
of certain glands in the intestine, catarrhal inflamma- 
tion of the mucous membrane lining the intestine, en- 
largement of the mesenteric lymph glands and the 
spleen, and an eruption of small rose-colored spots 
appearing in crops upon the chest, abdomen and flanks. 

Causation. — The disease is both endemic and epi- 
demic, and is found in all climates, although its severity 
may vary greatly in different places. It is more com- 
mon in the Eastern and Middle States than farther 
west, and occurs continuously in the larger cities, in 
which there are a certain number of cases to be found 
at all times. The most favorable period for the disease 
is the late summer and early autumn, and it is more 
prevalent and severe in dry than in wet seasons. Young 
adults (15 to 35 years) are more susceptible than 
children and old persons. When there is no difference 

82 



INFECTIONS OF CONTINUED TYPE. 83 

in the exposure, the infection is equally frequent in 
males and in females. As is the case with all infec- 
tious fevers, not all exposed persons acquire the dis- 
ease. Those in a debilitated condition are more likely 
to suffer from it than those in robust health, and some 
individuals seem to be more susceptible to the infection 
than others. One who has once had the disease seldom 
suffers from a second attack. 

The actual cause of the disease is the bacillus typho- 
sus, which was first described by Eberth in 1880. 
The bacillus gains entrance to the body usually through 
the alimentary tract, but may be breathed in with air 
contaminated by the dust of dried undisinfected stools. 
The germ is not destroyed by drying, and may live for 
months in the soil and upon clothing. It is not ren- 
dered harmless by freezing, and therefore the disease 
may be conveyed by ice. It may be taken into the 
body with water contaminated by sewage or milk 
from vessels washed with infected water, and upon 
vegetables which have been fertilized with sewage and 
oysters from beds near sewer exits. Flies may trans- 
mit the contagion by alighting upon food after having 
been infected from privies. 

Summary of Nursing in Typhoid Fever. — The pa- 
tient should be put to bed and kept in the recumbent 
position. He should be turned frequently to avoid 
bed-sores and hypostatic pneumonia. No pressure 
or friction should be made over the abdomen. The 
back should be kept clean and dry, and all prominent 
parts be well rubbed with alcohol, 50%, and dusted 



84 FEVER NURSING. 

with talcum powder. Fluid nourishment should be 
given every two hours, and the mouth, tongue and teeth 
cleansed with a mouth-wash before and after each 
feeding. The patient should have a daily bath. En- 
teric precautions should be started at once, and con- 
tinued until after convalescence. The nurse should 
see that the patient voids urine and that the bowels 
move regularly ; inspecting all stools for signs of haem- 
orrhage. The temperature should be taken every three 
hours, and complications carefully watched for. 

Mouth: The mouth, tongue and teeth to be washed 
before and after each feeding. Mouth-washes: anti- 
septic solution, glycerin and lemon juice, or tincture 
of myrrh, one drachm, sodium bicarbonate, ten grains, 
water, four ounces. 

Enteric Precautions: The nurse should thoroughly 
cleanse and disinfect her hands each time she waits 
on the patient. Separate dishes, utensils, thermometer, 
etc., should be provided. All linen, utensils, dishes, 
etc., should be disinfected after being used. Disinfec- 
tant should be kept in the bed-pan and, after use, more 
be poured over the contents, which must be covered 
and allowed to stand at least one half-hour before 
being emptied into the closet. All soiled linen, etc., 
should be carried in a foot-tub (never in the arms). 

Temperature: To be taken every three hours by 
rectum, unless otherwise ordered. It may be reduced 
by hydrotherapy: tub-baths, alcohol sponges, slush 
baths, cold compresses, cold packs. 

Dangers: Haemorrhage, perforation, peritonitis. 



INFECTIONS OF CONTINUED TYPE. 85 

Complications: Pneumonia, bronchitis, endocarditis, 
neuritis, thrombosis, phlebitis, abscess, peritonitis. 

Diet. — Nourishment should be administered at reg- 
ular intervals, both by night and by day. The appetite 
of the patient should not be consulted, for the subjects 
of typhoid are often apathetic and have no desire for 
food. The food (fluids) should be given at intervals 
of from two to four hours, according to the condition 
of the patient. Water should be given freely. Milk 
is the best diet, and it may be modified if necessary. 
Between one and three quarts should be taken daily, 
from four to eight ounces at a time. When modified, 
one to three ounces of lime water may be added to 
each glass of milk, or barley water and milk, equal 
parts, may be used. If the patient tires of the milk 
diet, or it disagrees with him, egg albumin, broth, 
eggnog, buttermilk or kumyss may be given. After 
the temperature has remained normal for from seven 
to ten days, the diet is usually changed to soft or light 
diet. 

The following menu for convalescents may be of 
value : 

First Day. — Milk toast or zwieback, crackers and 
milk, beef juice. 

Second Day. — Chicken broth thickened with well 
cooked rice or vermicelli, very soft-boiled egg (let 
stand off the stove in boiling water for ten minutes). 

Third Day. — Junket, beef broth, wine jelly, scraped 
raw beef. 

Fourth Day. — Lightly boiled or poached egg, arrow- 
root or barley gruel, chicken jelly. 



86 FEVER NURSING. 

Fifth Day. — Junket, well boiled rice, a small amount 
of white meat of chicken or squab, apple sauce. 

Sixth Day. — Scraped beef, poached egg, calves' foot 
jelly, baked custard, toast. 

Seventh Day. — A small piece of broiled steak or 
chop, baked potato, baked apple; well boiled rice and 
cream for breakfast, junket for supper. 

If the above diet agrees well and the temperature 
remains normal, the patient may gradually go on se- 
lected diet, such as 

Purees of peas, carrots, tender string beans. 

Meats: Roast chicken, squab or partridge, boiled 
white fish (trout), steak, chops. 

Vegetables: Spinach, cauliflower, asparagus tips, 
boiled rice, baked potatoes. 

Desserts. — Baked apples, apple sauce, junket, baked 
custards. 

For some weeks care should be taken with the diet. 
Green fruits, green corn, and crabs should be avoided. 

Nurses may infect their hands from stools, bath 
water, thermometers, etc., and laundresses who wash 
undisinfected clothing also may convey the bacilli to 
their mouths while eating with infected hands. The 
disease may likewise be transmitted by bath water which 
is splashed into the mouths of attendants. Many per- 
sons who drink the various bottled spring waters, 
hoping to avoid the disease, forget that the ice used 
may be contaminated and that infected water used in 
brushing the teeth is as dangerous as when drunk. It 
is important that the nurse should cool all mineral 



INFECTIONS OF CONTINUED TYPE. 87 

waters, etc., by placing the bottles upon ice, rather than 
by mixing cracked ice with them. 

The bacillus may be found in the faeces within five 
to ten days after the disease has begun, and it may 
remain in them not only during the attack, but all 
through the convalescence, though usually it disappears 
within about ten days after the fall of the temperature 
to normal. 

The urine contains the typhoid germ in a consid- 
erable number of instances, but as a rule not until com- 
paratively late in the disease. The organism often 
persists in the urine for some weeks after the patient 
has apparently recovered. It may also be found in 
the blood, the perspiration, the rose spots, the intes- 
tinal ulcers, and in the pus from abscesses which often 
complicate the disease, and it is probable that it exists 
in the expired air and in the sputum of cases compli- 
cated by bronchitis or pneumonia. 

The Onset of the Disease. — Usually typhoid fever 
develops gradually, and the patient may be quite unable 
to fix definitely the first day of his disease. In ordi- 
nary cases the day upon which he went to bed is con- 
sidered as the first day, but in hospital cases and many 
others the use of such a rule as a routine one will give 
rise to many errors. 

The usual mode of onset is as follows : The pa- 
tient notices slight chilly feelings, followed by feverish 
sensations, severe headache, nausea, vomiting and con- 
siderable prostration. Nose-bleed and cough are fre- 
quent early symptoms. Various unusual modes of 
onset may occur : 



88 FEVER NURSING. 

(a) Ambulatory or Walking Typhoid. — In this va- 
riety the patient keeps up and about and attempts to 
work. He realizes that he is not perfectly well, but 
feels hardly ill enough to go to bed. When he is first 
seen by the physician he may have a high fever and a 
well-developed rash. Such cases are likely to prove 
severe because of the lack of proper care in the early 
stages. 

(b) With Marked Gastrointestinal Symptoms. — 
The nausea may be severe and the vomiting almost 
continuous and very difficult of control. There may 
be profuse diarrhoea. 

(c) With Intense Pulmonary Symptoms. — The 
usual cough accompanying the onset may be much 
accentuated, and the chill and pain in the side be of 
such character as to strongly suggest pneumonia. 

(d) With Symptoms Referable to the Kidneys. — 
Dark or bloody urine containing albumin and casts 
may exceptionally be a feature of the onset. 

(e) With Pronounced Nervous Symptoms. — Agon- 
izing and obstinate headache or facial neuralgia may 
be initial symptoms. In some cases when the patient 
has kept about during the early weeks delirium may 
be the first symptom to appear. Rarely the disease 
may begin with twitchings of the muscles or convul- 
sions, stiffness of the neck, and dread of bright light. 
Drowsiness, apathy and stupor may exist for some 
days before other and more typical symptoms develop. 
Infrequently mania may be the first symptom. In 
alcoholic patients the various nervous manifestations 
are especially marked. 



INFECTIONS OF CONTINUED TYPE. 89 

(/) Hemorrhage from the Intestine or Perforation 
of the Bowel are very rare symptoms of the onset. 

The Course of the Disease. — The incubation period 
is from ten to twenty days (usually about two weeks), 
and the ordinary duration of the disease is four weeks. 
To each week belong certain symptoms. 

The typical temperature of typhoid fever is as fol- 
lows : During the first week the temperature rises regu- 
larly each day, being lower in the morning than in the 
evening, but day by day the difference between these 
temperatures becomes less. The temperature the sec- 
ond week is continuously high, and there is little dif- 
ference between that of the morning and that of the 
evening. In the third week the morning temperature 
becomes lower, while that of the evening remains as 
high as during the second week. The typical fourth- 
week temperature is one in which the morning tem- 
perature falls gradually lower, and that of the evening 
does likewise; dropping a little lower each day, until 
both it and the morning temperature reach normal. 
On the page following is depicted the chart of a typical 
case of typhoid fever in which the temperature has 
been uninfluenced by antipyretic drugs or baths. 

Complications may alter the course of the temper- 
ature. Intestinal haemorrhage and perforation are 
usually followed by a rapid and considerable fall. In 
fatal cases the temperature is likely to continue high 
until death. The height of the fever is, as a rule, in 
direct proportion to the severity of the disease, but in 
some fatal cases the temperature may never reach a 
very high level. 



9° 



FEVER NURSING. 



TEMPE 
t i 1 rift i! ilt rrr n 1 n 


RATLTRE (OentigTade) 

CO CO cc 
If 1 1 1 1 1 1 Ml II ll 1 III IT 1 


CO 

IIIIMIll 




«■* __3 : _ : 


:. : :_ _____ __£ ::± 








<a 


± 












__X 










__: :__ ::± 












. _ _ : ::::: _: :::± 








•<» 


± 












::::::::: — :± 








<a 


:__:__: :___::± 










O.S 


________ _^ 










± 












:::: ::::::::: — :x 










:± 










a. a 


: — :± 








<2 


:__: :___:__: :± 










a. a 


:::::: :: ::: ::: : :± 








<ar 


± 












__ :::: __ _s,± 










is: 










S3 


::::: :::::::: — jet 








■o= 


___£ 








§3 


'£.'£; ' 


::::::: ::: ::: isx 








^__:_: : :__: 










CO 


Zs 










<- 










§5 




: "i"::: - : - : — _s"X 








<s 


_s- 




1 


i 


S 


cci" 


- '?: . i 










251 X 








00 


°-.2E 


<t' 










,____§: x 








& 


"V s 


• , =^~ 








<s 


_:-5r -t- 








£ 












<* 










8 


«.«* 


<s!'__ 








<a 


_:w 








c5 




j_ ________ — :::::: ::± 


















CO 


«-S «sfc 


^n 








<a 


'-_j- T 








c* 

©» 


-- «-- 










<aE + 


3s» 








a 


is: 










<_ "K- 










3 












r<z ~*t 










OS 


£=. _ *!__p 




X 


-_X 




00 


-=::::::::":::'":"===:": 


j-_____ _L 


T" 


— r 


TTI 


i| :_-: 




1 


1 


l i 


£ 


<a 




+ 


i 


IN 


50 


<3 ->• 




+ - 


--+ 


TIT 


M3 


°-" <~ 










<* ?. 










-* 


= ________ ---- 










< as __:• 










a 


-* :~~:~~ ::«?!:!::: 










<- >• 










a 


«-_ < 










<a ^> 










a 


i_: 










<=: :: i_:_fc:: 










o 


0.3 <- 










<" .5" 










o> 






















00 


: .si!::: 










<- ;:_: *§::: 










fc- 


«.*. <; 










<* * s 










«o 


iS __ 










si::::: ::___ 










-3 


m <, 










ag _*: 










<* 












Sa 


■ B "pi 




i 


. 


CO 


S| 


$ — ---__ _ _ X 




X 




<N 


£2 

%F - 


X£;=J- h 


X"" 


-4- 


~Ht 


3a 










H 


a__ 










■?_ 










$1 

Q 


1 § § £ u | ° 

* ■ (^aqnaaqBj) 


1 "1 "S "1 "8 p| "S5| u £ 



INFECTIONS OF CONTINUED TYPE. 9 1 

The pulse usually bears a direct relation to the tem- 
perature curve. In the first week it is full, strong and 
of 90 to 100 beats to the minute; during the second 
and third weeks it is likely to become more rapid, 
feeble and perhaps dicrotic. 

Various deviations from the typical temperature 
curve are frequent. When the disease begins with a 
chill the fever may rise at once to 103 F. (39.5 C.) 
or 104 F. (40 C). Often defervescence takes place 
at the end of the second week, and the temperature 
may fall to normal within twenty- four hours. A tem- 
perature higher in the morning and lower in the even- 
ing may occur, but has no particular significance. 
Sudden falls of temperature may take place, and usually 
indicate intestinal haemorrhage or perforation. Hy- 
perpyrexia (temperature above 106 F. — 41. i° C.) is 
rare, but may occur just before death. 

There may be chills at the beginning of the disease, 
at intervals during its course, with the onset of com- 
plications, after the use of antipyretic drugs, and during 
convalescence, without assignable cause. 

Sweats may accompany the chills, but profuse per- 
spiration is rare, though the abdomen and chest may at 
times be moist, especially during the reaction from a 
bath. 

Rises of Temperature After Defervescence {Re- 
crudescences) may take place even after there has been 
no fever for several days. Such rises may last for a 
number of days and then disappear. With these there 
is no constitutional disturbance, but they are, neverthe- 



9 2 FEVER NURSING. 

less, causes of anxiety. They are usually due to im- 
proper feeding, constipation, or unwonted mental ex- 
ertion. 

There are cases in which convalescence has appar- 
ently become established but which continue to have an 
evening rise of temperature of one or two degrees (F.). 
This may be due to starvation, but should cause one 
to search for complications. In excessively nervous 
patients such an evening rise is a frequent occurrence, 
but if the patient show no other symptoms it may be 
disregarded. It often disappears if the patient be 
allowed to sit up and be given solid food in small 
quantity, and the use of the thermometer be discon- 
tinued. 

Relapses are due to a fresh infection, and may last 
varying lengths of time, but as a rule they are shorter 
than the original fever. The temperature rises and 
declines gradually, and is accompanied by a return of 
the symptoms. 

Afebrile Typhoid (typhoid fever without rise of 
temperature) has been observed, but is of very rare 
occurrence. 

Symptoms — The Facial Appearance. — Early in the 
disease the face is flushed and the eyes are bright; by 
the beginning of the second week the expression be- 
comes apathetic, and at the height of the infection it 
is dull and listless. The lips and cheeks may retain a 
good color throughout the disease. 

The Skin is usually dry. The typical eruption of 
typhoid fever appears in crops from the fifth to the 



INFECTIONS OF CONTINUED TYPE. 93 

twelfth day of the disease and consists of small, iso- 
lated, rose-colored, slightly elevated, round or oval spots 
of about the diameter of a pinhead (two to four milli- 
metres) . They disappear on pressure, but immediately 
reappear when pressure is removed. They are seen 
earliest upon the back, and slightly later upon the front 
of the chest and abdomen. They may be found upon 
the arms and thighs, but very rarely upon the forearms 
and lower legs. They appear in successive crops, each 
crop lasting two to four days, while the whole eruptive 
period lasts from two to twenty-one days. Relapses 
show a fresh eruption, and the spots may appear after 
the establishment of convalescence. Some cases show 7 
no eruption whatever. 

The Typhoid Tongue is at first moist, and down its 
centre is a strip of whitish fur; its edges and tip are 
red. In mild cases the tongue continues moist through- 
out the disease, but in severe cases it becomes dry, 
brown and cracked. Rarely it may remain clean, but 
become dry, glazed and fissured in the later weeks. 
As convalescence progresses the tongue gradually re- 
assumes its normal appearance. 

A Typical Case of Enteric Fever. — During the 
period of incubation of from ten to twenty-one days 
the patient suffers from indefinite feelings of languor 
and is disinclined toward exertion of any sort. He 
lacks energy and may complain of general muscular 
soreness. 

First Week. — At the invasion of the disease there 
are indistinct chilly feelings (rarely a distinct chill), 



94 FEVER NURSING. 

severe frontal headache, and pains in the back and 
limbs; the tongue is coated down its centre, its edges 
and tip are redder and the papillae more prominent 
than usual. There may be spontaneous nose-bleed 
and there is often cough due to slight laryngitis or 
bronchitis. 

The eyes are suffused. The patient feels feverish, is 
thirsty, and complains of weariness, sleeplessness and 
nausea, which is of ten accompanied by vomiting. Con- 
stipation is the rule, but there may be diarrhoea. There 
may be sore-throat with pain on swallowing. 

Patients during this stage of the disease may con- 
tinue up and about (walking typhoid), but usually they 
find that they are more comfortable in bed. The tem- 
perature of the first week has been described. By the 
fifth or sixth day it reaches an evening height of 103 
to 103.5 F. (39.5 to 39.8 C). The pulse is rapid, 
strong and bounding, 90 to 100 per minute, and very 
rarely may be dicrotic. By the end of the week the 
typical fades of the disease appears and the expression 
is dull and lethargic. A few spots may have shown 
themselves and the spleen may be palpable. 

Second Week. — As the second week progresses all 
the symptoms become accentuated, with the exception 
of the headache, nausea and vomiting. These usually 
cease. The temperature continues high (103.5 to 
104 F. — 39.8 to 40 C), with slight morning remis- 
sions. The pulse becomes softer, feebler and more 
rapid (100 to 120). Bodily weakness is pronounced, 
and the patient has no desire to move. Early in the 



INFECTIONS OF CONTINUED TYPE. 95 

week the rash becomes evident. The tongue is dry, 
brown and tremulous ; there is likely to be diarrhoea, 
with three to five thin pale yellowish-brown stools a 
day (pea-soup stools). Mild delirium may appear late 
in this week ; at first it may be present only at night, but 
later it lasts through the day as well, and the patient 
shows other signs of great nervous weakness, such as 
avoidance of light, slight deafness, and twitching of 
the muscles. If there is no delirium the patient is 
very stupid, takes no interest in his surroundings, and 
makes no requests. 

Third Week. — The symptoms of the second week 
continue and become more pronounced. The tempera- 
ture continues high, but as the week nears its close the 
morning temperature is likely to fall to a lower level 
(ioi° to 102° R— 38.3 to 38.9 C). The pulse may 
become very rapid and weak, and perhaps dicrotic. 
The tongue becomes more dry and cracked, and the 
patient may be unable to protrude it. Bed-sores may 
appear, and retention of urine and incontinence of 
faeces occur. The nervous symptoms grow more 
marked, the twitchings are more noticeable, and the 
patient may pick at the bed-clothes and grasp at imagi- 
nary objects. Intestinal haemorrhage may be evidenced 
by blood-tinged stools, or blood in considerable quan- 
tity may flow from the rectum, leaving the patient in 
collapse, with a sudden fall in temperature, impercep- 
tible pulse, and other evidences of extreme prostration. 
Congestion of the lungs or pneumonia is liable to 
complicate the disease in this week. Distention of the 



96 FEVER NURSING. 

abdomen by gas is not infrequent. The patient may 
die or go on to 

The Fourth Week. — Now the morning temperature 
falls still lower and the evening rise gradually becomes 
less, until the former reaches normal and the evening 
ioi° to 102° F. (38.3 to 38.9 C). As the fever 
diminishes the other symptoms gradually ameliorate; 
the tongue becomes moist and the pulse stronger, and 
the nervous manifestations disappear. A returning 
appetite may evidence the patient's improvement. 

The Fifth Week. — The patient may go on to com- 
plete recovery, the fever may last two or three weeks 
longer in severe cases, or, after a normal temperature 
lasting several days, a relapse may take place. 

Convalescence is slow. The patient is extremely 
weak, although he feels well and is extremely hungry. 
He is able to sit up only a few minutes at a time, and 
walking is well-nigh impossible. Relapses may be 
brought on by slight errors in diet or by over-exertion. 
The patient should not be allowed up for at least a 
week, and he should not be permitted to walk before 
the tenth day. There is usually some loss of hair, and 
in females dysmenorrhoea may occur. Full strength 
may not be recovered for a number of months. 

Menstruation usually takes place early in the disease 
as in health, but in the later weeks and in convalescence 
may be absent. Pregnant women, though they rarely 
contract typhoid fever, are very apt to abort during its 
course. 



INFECTIONS OF CONTINUED TYPE. 97 

Complications. — Thrombosis of the veins is a fairly 
frequent complication, and is caused by the stoppage 
by a clot of the flow of blood through a vessel. It 
occurs most often in the veins of the thigh and is indi- 
cated by swelling, oedema and tenderness of the affected 
part. 

Hcemorrhage from the Intestine occurs in about four 
per cent, of all cases ; there may be only slight streaks 
of blood in the stools or a free haemorrhage which 
may or may not result in death. It is usually caused 
by the ulcers in the intestine destroying the coats of 
the blood-vessels, and is most frequent in the third 
week. It may appear without warning, and, if large, 
results in immediate collapse with its attending symp- 
toms. 

Perforation of the Bowel is less frequent, and is the 
most serious complication of the disease. It occurs 
usually in the third week and is the result of the ulcers 
eating their way entirely through the wall of the intes- 
tine; a catastrophe usually evidenced by sudden acute 
pain in the abdomen, rapid fall of temperature, and 
marked collapse. Peritonitis results, and this is indi- 
cated by vomiting, abdominal distention, tenderness and 
rigidity. 

Peritonitis, without perforation, may occur by ex- 
tension of the inflammation within the intestine to the 
peritoneum surrounding it. 

Abscesses in various parts of the body (mostly in 
the parotid glands) may appear. These give the usual 
symptoms of abscesses from ordinary causes. 
8 



98 FEVER NURSING. 

Typhoid Spine is a rare complication, and is the 
result of inflammation of and around the bodies of the 
vertebrae. 

Bronchitis of mild or severe type occurs frequently 
at the onset and is evidenced by cough and more or 
less muco-purulent expectoration. 

Pneumonia may complicate the disease early or in 
the later stages. In the latter case it may be over- 
looked, for frequently the symptoms are not well 
marked. 

Neuritis (inflammation of the nerves) is fairly com- 
mon, and may occur during the course of the disease 
or in convalescence. Its onset is marked by great pain 
and tenderness along the course of the affected nerves. 
There may be a slight degree of paralysis, usually in- 
volving the extensor muscles of the limbs and evi- 
denced by wrist- and foot-drops. 

Bed-sores may develop in severe cases and in those 
not well cared for. They are an unnecessary and dan- 
gerous complication. 

Albuminuria is common, and when merely due to 
the infection is of little significance. It may, however, 
indicate a true nephritis. 

Phlebitis, especially in the femoral vein, is occasion- 
ally encountered. 

Various other complications are described, but are of 
more or less rarity. 

Typhoid Fever in Children. — The disease is fairly 
common in children, but is rare in infants. Its course 
is mild and the symptoms, except the mental dulness 
and apathy, are usually not well marked. 



INFECTIONS OF CONTINUED TYPE. 99 

Typhoid Fever in Old Persons. — After the age of 
forty the disease is rare, but of severe course, and 
although the temperature may not reach a high level, 
complications, especially pneumonia and heart-weak- 
ness, are frequent. 

The Widal Reaction is an aid in the diagnosis of 
the disease, and is based upon the fact that the blood 
of a typhoid patient when added to a culture of the 
bacillus of Eberth causes the organisms to aggregate 
into " clumps " and to lose their motility. In the city 
of New York the Health Department employs bacteriol- 
ogists who make this test upon specimens of blood 
sent in by physicians. A specimen is prepared by 
drawing from the patient's ear and collecting upon 
either end of a glass slide two good-sized drops of 
blood. These are allowed to dry, and the specimen 
is then ready for examination. 

Prevention. — Since the disease is caused only by 
the entrance into the system of bacilli from other 
patients, the greatest attention on the part of the nurse 
should be given to the proper disinfection and disposal 
of all excreta. It is entirely insufficient to empty these 
into the various receptacles provided for their disposal ; 
instead, it is absolutely necessary that they should be 
properly disinfected according to methods such as those 
described on page 79. Likewise the bed-clothing, bath 
water, the patient's garments, and all objects and uten- 
sils with which he or the nurse, after handling him, 
comes into contact, must be subjected to thorough dis- 
infection before being used again. After his recovery 

LOfC 



ioo FEVER NURSING. 

the sick-room with all its furniture should be treated 
in accordance with the directions laid down in the 
section upon room disinfection. 

The typhoid fever patient is unlikely to be a source 
of danger to those about him, provided these precau- 
tions are taken and the nurse is scrupulously clean in 
dress and person, always changing the former, steriliz- 
ing her hands, and washing her face before going to 
meals and upon leaving the sick-room for exercise, etc. 
She should also be very careful never to use her mouth 
as a receptacle for pins, pencils and the like, since care- 
lessness in this regard may cost her her life. 

Anti-typhoid Inoculation. — Recently attempts have 
been made with some success to prepare a serum which, 
when injected into healthy persons, may render them 
immune to typhoid fever, and experiments which were 
made upon the English soldiers during the Anglo-Boer 
war in South Africa lead us to believe that individuals 
so inoculated are much less prone to contract the dis- 
ease, while, when they do suffer from it, they are 
much more likely to recover than those uninoculated. 
Unfortunately, immunity so conferred lasts only for a 
period of weeks. It may be safely affirmed that the 
measure is one which, in properly selected cases, is not 
dangerous, and it should not be neglected when there 
it probability of exposure to the disease. 

Treatment. — The specific treatment of typhoid fever 
by means of an antitoxin has as yet given no very 
favorable results. 



INFECTIONS OF CONTINUED TYPE. 101 

The value of the antiseptic treatment of typhoid 
fever has never been questioned. The only difficulty 
is how best to secure its efficiency. This may be done 
most efficaciously by the administration early in the 
disease of certain intestinal antiseptics, such as beta- 
naphthol bismuth, or eudoxin, and, after the first 
week, of the official compound solution of chlorine in 
one or two drachm doses every three or four hours. 
In such doses the chlorine solution can be safely admin- 
istered until complete disinfection of the alimentary 
tract is obtained. Under its use the tongue becomes 
cleaner, the appetite and digestion better, the fever 
lower, and the stools devoid of odor, save that due to 
chlorine. The general strength, intellectual processes 
and nervous conditions improve, the disease is short- 
ened, and the patient usually proceeds to a rapid and 
complete recovery. 

During the course of the disease a daily movement 
of the bowels should be secured by means of rectal 
enemata. 

At the present time the treatment of typhoid fever 
by the Brand, or more properly the Currie-Jiirgensen, 
bath, is enjoying considerable vogue. Brand's original 
method has been modified, so that the consensus of 
opinion is now in favor of tub bathing at a tempera- 
ture of from 8o° to90° F. (26.7 t0 32.2° C), although 
certain authorities believe that tubbing at 98 F. 
(36.7 C.) produces quite as good results, while much 
less disturbing to the patient. The duration of the 
baths is usually ten minutes. The patient should be 



io2 FEVER NURSING. 

lifted both into and out of the bath; he should be 
immersed to the neck and his head covered with an 
ice-cap or cold cloth. Throughout the procedure he 
should be gently but thoroughly rubbed by the hands 
of at least two attendants. Stimulants should follow 
the bath and in weak patients should precede it. At 
the conclusion of the measure the patient should be 
dried in the recumbent posture, and, if chilly, warmly 
covered. Fresh water should be used for each bath. 

Spongings, sprinkle baths, cold wet packs, evapora- 
tion baths and the application of cold water-bags may 
be used when tubbing is contra-indicated, but are much 
less efficacious. Perhaps the best substitute for the tub 
bath is the bed bath (see p. 38). 

The frequency of the baths is governed by the height 
of temperature, the severity of the nervous symptoms, 
the strength of the pulse, and the general condition. 
Old age, as well as the slightest indication of haemor- 
rhage, peritonitis, extreme heart-weakness, arterio- 
sclerosis, pneumonia, pleuritic effusion, or phlebitis are 
contra-indications to tub bathing. The menstrual period 
and pregnancy do not absolutely contra-indicate. Obese 
persons should be bathed with care. There are pa- 
tients who, for no apparent reason, do not bear tubbing 
well, and in such cases it is wise to omit the process. 

When heart-weakness occurs in the course of the dis- 
ease it may be counteracted by alcohol and other stim- 
ulants. The headache, restlessness, sleeplessness and 
delirium may be controlled by hot or cold applications 
and sedative drugs. Bismuth and opium may be given 



INFECTIONS OF CONTINUED TYPE. 103 

if the stools become too frequent. The genito-urinary 
tract may be rendered less septic and the urine less in- 
fectious by the administration of hexamethylenamine 
(urotropin) in doses of five grains three times a day. 
The drug should be well diluted and thoroughly dis- 
solved, and must be given with care. It is well to use 
it in the later weeks of the disease and during conva- 
lescence, if not throughout the whole course of the 
infection. 

Neither this nor any of the drugs mentioned above 
must ever be given by the nurse save when directed by 
the attending physician. 

The disease in children may be managed in practi- 
cally the same manner as in adults. Tub baths, how- 
ever, are less well borne, and fortunately the disease 
runs a milder course in the younger patients. 

The Treatment of Complications. — x\t the least 
sign of intestinal hemorrhage the strictest quiet must 
be enjoined, the patient must not be moved even to 
have his soiled linen changed, and food must be tem- 
porarily stopped. When feeding is begun again, only 
such foods as are digested in the stomach and upper 
part of the intestine, such as beef-juice or peptonized 
milk, should be given, and these in very small quan- 
tities at a time. If the patient is being bathed, the 
baths must be omitted. Applications of cold in the 
form of compresses or the ice-coil should be made to 
the abdomen. If there are signs of collapse, the foot of 
the bed must be raised and, upon the physician's order, 
hypodermatic stimulation administered (whiskey), 



104 FEVER NURSING. 

while hot normal salt solution, injected either directly 
into a vein or under the skin of the thighs or buttocks, 
may be necessary. Drugs calculated to stop the bleed- 
ing may be ordered by the medical attendant. 

Perforation of the Bowel. — When perforation takes 
place absolute quiet is necessary until a surgical opera- 
tion can be performed, and this should be done as soon 
as possible after the diagnosis has been made. 

Peritonitis calls for the enforcement of complete 
quiet, the application of cold to the abdomen, and great 
care in the administration of food. 

Tympanites (abdominal distention by gas) may be 
diminished by the insertion of a rectal tube, by the 
application of hot-water bags or turpentine stupes to 
the abdomen, by the administration of a few drops of 
turpentine internally, or by high rectal injections of 
hot saline solution upon the physician's order. Often 
by stopping the milk for from twenty- four to forty- 
eight hours we may prevent the formation of gas. In 
the interval, broths and albumin water may be given. 

Thrombosis is treated by the elevation of the affected 
part and by cold applications. The patient must re- 
main quiet, lest portions of the clot, becoming dis- 
lodged, get into the circulating blood and cause throm- 
bosis elsewhere. 

Bed-sores should be guarded against by the strictest 
attention to cleanliness and by the other precautions 
mentioned on page 46. 

Constipation may be overcome by mild laxatives or 
by enemata of soapsuds. The latter should not be 



INFECTIONS OF CONTINUED TYPE. 105 

large and must always be given from a fountain 
syringe, with great care, and only upon the physician's 
order. 

Recrudescences and Relapses. — The management of 
the latter is identical with that of the disease itself, but 
the former are a more serious matter ; in them only the 
mildest hydrotherapeutic measures should be used, and 
heavy stimulation may be necessary. 

The Diet. — While the febrile movement is present 
only fluid diet is allowable. Most patients do well upon 
a diet of milk alone (see pp. 58, 85). The milk may be 
cold, warm or boiled, as the patient prefers. It may be 
more acceptable if a little Vichy or other carbonated 
water be added, or if flavored with a few teaspoonfuls 
of French coffee. When milk cannot be tolerated, mat- 
zoon, kumyss or buttermilk may be substituted. If 
milk disagrees, the tongue becomes heavily coated and 
tympanites, constipation or diarrhoea with undigested 
curds in the stools may ensue. Such symptoms may 
be relieved by diluting the milk with equal parts of 
lime water or Vichy, by peptonizing the milk or by 
replacing it with a diet of beef, lamb or chicken broths 
and albumin water. The broths may prove more pala- 
table when flavored with various vegetable extracts 
(onion, celery, etc.). The different prepared foods 
(malted milk, plasmon, etc.) and gruels may be tried; 
an occasional cup of cocoa will do no harm. 

If the patient goes to sleep quickly after being 
wakened, feeding should be continued at proper in- 
tervals during the night ; otherwise one or two feedings 
should be omitted. 



io6 FEVER NURSING. 

The nurse must always record the total quantity of 
food taken each day. 

Fluid diet as a rule should be continued for at least 
one week after the temperature has fallen to normal, 
but some patients, after all the symptoms have disap- 
peared, continue to have an evening rise of temperature 
of two or three degrees (F.) ; to such, if the nutrition 
is impaired and the need of food is manifest, a gradual 
return to solid diet may be allowed. Usually the tem- 
perature promptly subsides and no harm is done. 

The articles of solid food which are allowed first are 
puree soups, broths with rice, milk toast, soft-boiled 
e ggs> junket and the like (see p. 85). 

Relapses and recrudescences necessitate an imme- 
diate return to fluid diet. 

Nursing. — In a private house the bed should, when 
possible, be in a large, light, well-ventilated room from 
which all hangings and superfluous furniture have been 
removed. The temperature should not be above 70 
F. (21. 1 ° C), and it is better to have it as low as 
6o° F. (15.5 C). In favorable weather the windows 
should be open. Too bright light and too much dark- 
ness are equally to be avoided. The bed should not 
be too heavily covered, and the bed linen must be 
frequently changed and kept perfectly smooth. In 
severe cases the air or water bed may be necessary. 
Early in the disease the patient should lie on his back, 
but later the nurse should encourage him to change his 
attitude, in order to guard against pulmonary con- 
gestion and bed-sores. The mouth, teeth and tongue 



INFECTIONS OF CONTINUED TYPE. 107 

should be frequently cleansed. Studious attention 
should be given to the proper cleanliness of the body, 
and all points at which bed-sores are likely to develop 
should receive special care. The bowels and bladder 
should be evacuated only when the patient is lying 
on his back; the stools must be carefully watched for 
blood and milk-curds, and if these occur they must 
be at once reported to the physician. The quantity, 
color and sediment of the urine must be noted. 

When involuntary movements and urination are un- 
avoidable, the soiled bed-clothing, which should be 
promptly disinfected, must be immediately replaced 
by clean linen. In such cases the change is greatly 
facilitated by having two beds and moving the patient 
when necessary from one to the other; at least two 
attendants are necessary for this process, since the 
patient must remain absolutely passive. 

The apartment should be kept quiet and free from 
disturbance of any kind, for complete mental inactivity 
on the part of the patient is necessary. On this account 
visitors and all distractions should be forbidden. 

It is best to have two nurses, and a member of the 
family may be allowed in the room when additional aid 
is needed. The bed should be of single size and high, 
with a firm, comfortable mattress protected by a rubber 
sheet. The clothing under the patient must be kept 
smooth to prevent bed-sores, and in warm weather if 
he wears no night-shirt, and is covered only by a sheet, 
he will be more comfortable and will be spared the 
inconvenience of being undressed for each bath if 



io8 FEVER NURSING. 

baths are given. Under these circumstances wrinkling 
of the clothing under him will be less likely to occur, 
and the possibility of taking cold is very slight. 

The patient's head should be kept low, and nourish- 
ment should be administered through a tube or from 
a spouted cup. Temperature, pulse and respiration 
should be taken every three hours, but at night, unless 
the fever is above 103 F. (38.5 C), it is wise to 
allow the patient to sleep without interference. He 
should not be allowed to see the temperature chart lest 
this occasion undue worry about his condition. 

If the mind is clear it is well to explain the danger 
of attempting to sit up and of sudden movement, and 
if there is the least sign of mental aberration or de- 
lirium the patient must not be left alone for an instant. 

The nurse should assist the patient to change his 
position at intervals during the later weeks of the dis- 
ease, even if he does not complain of discomfort. 

On points other than those mentioned above the 
nursing of enteric fever should be carried on in accord- 
ance with the principles laid down in the sections on 
fever nursing in general. 

Paratyphoid Fever. 
This disease differs in no essential from true typhoid 
fever except in its cause. This is a bacillus inter- 
mediate in form between the true typhoid bacillus and 
the common colon bacillus. The symptoms, course, 
treatment and nursing of the two diseases are practi- 
cally identical; in fact their differential diagnosis is 



INFECTIONS OF CONTINUED TYPE. 109 

impossible except by demonstrating the organism in 
the patient's blood or excreta. All that has been said 
in the previous section with regard to typhoid fever, 
except the paragraphs upon preventive inoculation and 
serum treatment, applies also to the paratyphoid infec- 
tion. In the latter disease the sera for preventive in- 
oculation and treatment must of necessity be products 
of the growth of the paratyphoid bacillus. 

Weil's Disease. 

Synonym. — Acute Febrile Jaundice. 

Definition. — Weil's disease is an acute infectious 
fever, characterized by severe pains in the muscles, 
jaundice, nephritis, and a remittent temperature, which 
falls by crisis or rapid lysis. 

Causation. — It usually occurs in the summer months 
and is most commonly seen in young adult males. Its 
specific cause is probably a microorganism which has 
not yet been identified. 

Course and Symptoms. — The incubation period is 
usually about one week. The onset is sudden, with 
a chill followed by fever, headache and severe pains 
in the muscles. About the second day there is jaun- 
dice, which later may become more pronounced, and it 
is accompanied by itching. The temperature ranges 
from about 103 to 104 F. (39.5 to 40 C), but may 
reach 107 F. (41. 6° C). There may be vomiting 
and diarrhoea ; rarely there is delirium or coma. The 
liver and spleen are enlarged and tender ; the urine con- 
tains bile pigment, albumin, casts and perhaps blood. 



no FEVER NURSING. 

The stools may be clay-colored. The disease usually 
continues from five to eight days, when the fever falls 
and the symptoms abate. The mild cases usually re- 
cover rapidly, the more severe ones may be protracted ; 
ultimate recovery, however, is the rule. 

The disease derives particular interest from the fact 
that it is easily confounded with enteric fever. 

Treatment. — The treatment is entirely sympto- 
matic. The headache may be relieved by compresses, 
the muscular pains may be controlled by rubbing with 
some counter-irritating liniment, the bowels should be 
kept open, and during the febrile stage the patient 
should be kept in bed. 

Diet. — The nephritis present makes a fluid diet abso- 
lutely necessary. When the temperature has fallen and 
the nephritis has subsided, a gradual return to ordinary 
diet is proper. 

The nursing is to be conducted along general lines. 

Typhus Fever. 

Synonyms. — Jail, Camp, Ship, Hospital, Putrid or 
Spotted Fever ; Black Death. 

Definition. — An acute infectious disease charac- 
terized by a typical skin eruption, nervous symptoms, 
and a high temperature, terminating usually by crisis 
in about two weeks. The disease was very common 
in former times, but is becoming comparatively rare 
because of the increased attention paid to sanitation. 

Causation. — It is most common in young adults, 
but no age is exempt. Filthy conditions, unhygienic 



INFECTIONS OF CONTINUED TYPE. m 

surroundings, poor ventilation, etc., favor the occur- 
rence of the disease. Typhus fever is probably caused 
by a microorganism which has not yet been discovered. 
The contagion is easily acquired and difficult to destroy ; 
it seems to float in the air and to be given off from the 
surface of the patient's body ; consequently the disease 
is communicable from person to person and through 
clothing, bedding, furniture and the like. The contagion 
cannot, however, be carried through the air from hos- 
pitals to dwellings in the vicinity. Typhus patients 
give off in the breath and from their bodies a peculiar 
odor, and persons who perceive this most acutely seem 
to be most apt to contract the disease. If the sick- 
room is thoroughly ventilated, visitors spending only a 
few moments with the patient are not likely to become 
infected. It is believed that the patient's excreta do 
not spread the disease. Typhus fever is most easily 
contracted by persons in poor condition and unhealthy 
surroundings, but few escape if sufficiently exposed. 
It is unusual for one individual to suffer two attacks. 

Course and Symptoms. — The incubation period 
varies from a few hours to twenty days. These ex- 
tremes are rare, however, the usual period being from 
eight to twelve days. The average duration of the 
disease is from twelve to fourteen days. 

The most noticeable symptoms are fever, headache, 
mental symptoms, and the eruption. 

The onset is usually sudden, with a chill followed 
by fever, severe headache, and pains in the back and 
limbs ; there may be nausea and vomiting ; the bowels 



H2 FEVER NURSING. 

are usually constipated. During the first week the 
face is congested and apathetic, presenting a peculiar 
appearance, so that once seen it is always recognized, 
and during the second week the patient's appearance 
resembles that of the third week of typhoid fever. 
After the initial chill the temperature rises rapidly and 
reaches its greatest height (usually 104 to 106 F. — 
40 to 41. 1 ° C.) from the fourth to the seventh day. 
At first the fever is practically continuous, but as the 
second week begins there are morning remissions. 

The pulse is at first rapid (100) and full; later it is 
likely to become rapid and feeble, or it may remain 
slow and feeble or rapid and feeble throughout the 
disease. 

The respirations are rapid, and this rapidity may 
be increased during the second week as a result of 
pulmonary complications. 

The rash is constant; it appears from the fourth 
to the seventh day and lasts for from seven to ten days. 
There is but one crop, and it is seen on the arms, legs 
and trunk ; being most typical on the front of the fore- 
arms and shoulders. It is in the form of irregular, 
slightly elevated, rounded, pinkish blotches, from the 
size of a pinhead to that of a split pea. Later in the 
disease the spots become darker in color and the inter- 
vening skin may be reddened or mottled. From the 
eighth to the tenth day small ecchymoses within the 
blotches, which have now become brownish in color, 
may appear, and small bluish petechise may also mani- 
fest themselves. These last may persist after the dis- 



INFECTIONS OF CONTINUED TYPE. 



IJ 3 



appearance of the original rash. After the eruption 
has disappeared desquamation usually takes place. 
Children, in whom the disease is rarely fatal, sometimes 
show no rash whatever, and are quite likely to be free 
from the petechiae. 

The urine is diminished, darkened in color, and in- 
creased in acidity, and is likely to contain albumin 
and casts. 

The marked nervous symptoms, such as alternating 



DAY OF -t I 
DISEASE X 


I 3 4 


5 


G 


7 i 


\ 9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 




MOM m W M 


M M M M 1 


A 
M I 


M h 


M M M 


P A P 
M M M 


H 


M ? 


¥ V 




s 


■ 


5 


s 


E 


M A 


s 


MU 


M 


U 


M 


H 


M 


M 


M M 


M 


H 














































































































tnn 






















































- 


HIL . 
























































































































































































































106 1 
















































— 



























































-41 

H 
W 

I K 

I > 
- H 

C 

— 89° £ 






















































~ 105 ' 




























































^ A ' 














































A * 


1 




: h 3j 












































•9 o -i 


*5 - 


/ 




-w 3 












































c 204 /■ 




/ 




V v 












































I * 
















































5_ 


•d 










































■5 -W 














































« C * 






























































































































































































Pi 




















































2 < 




















































B 102--- 




















































< — 
























































3 c 






















































a ioi=^=- 






















































o. - 1 -- 






















































-38°^ 


S - 






















































a 100==- 






















































t-« " , 






















































Q. 
O 

-87 
























































99 








































































































- = ==; 




















































—36 




. 




















































97 ==- 






















































96 

























































Clinical Chart of Typhus Fever Ending in Recovery. 



delirium and stupor, muscular twitching, picking at 
the bed-clothing, etc., appear in the second week. 

In the favorable types of the disease, at the end of 
the second week the temperature falls rapidly, the 



H4 FEVER NURSING. 

symptoms subside, the patient is able to sleep, and 
convalescence ensues. 

Relapses are rare, and bronchitis and broncho-pneu- 
monia are the most frequent complications. 

The prognosis of typhus fever is always grave. 

Prevention. — The spread of the disease should be 
guarded against by isolation of the patient and the 
strictest quarantine. All the excreta, bed-clothing, 
utensils, the sick-room, etc., should be disinfected as in 
typhoid fever. It is very important that the apartment 
should be thoroughly aired for several weeks after 
having been subjected to the process of disinfection. 

Treatment. — The patient should be confined to bed, 
his diet should consist entirely of fluids (milk, broths 
and the like), and he should be encouraged to drink 
copiously of cold water. After convalescence has 
begun solid diet may be allowed within a few days. 

No drug is known which exerts any specific influence 
upon the disease, and the symptoms are treated as they 
arise. 

It is of the utmost importance that there be an 
abundance of fresh air in the sick-room. During the 
last epidemic in New York it was found that those 
patients bore the disease best who were treated in tents 
in the open air. 

For the fever, if above 102 F. (38.9 C), cold 
baths may be given; the bowels should be kept open 
by mild laxatives ; the employment of whiskey or other 
stimulants may be necessary to combat the heart-weak- 
ness. For the nervous symptoms various sedatives 
are indicated. 



INFECTIONS OF CONTINUED TYPE. 115 

The nurse should endeavor to spend most of the 
time, when not in actual attendance upon the patient, 
near an open window or in fresh air. Otherwise the 
nursing of the disease should be conducted along the 
lines laid down for the nursing of febrile disease in 
general. 

Yellow Fever. 

Definition. — An acute infectious febrile disease 
evidenced by jaundice, vomiting of blood, and extreme 
prostration. The disease is endemic in the West Indies, 
Central America, and the west coast of Africa. From 
time to time epidemics have appeared in the Southern 
United States and also occasionally in the Middle 
States. 

Causation. — The specific germ of yellow fever has 
not yet been discovered beyond question. It is trans- 
mitted to man through the bite of a certain species of 
mosquito which has previously fed upon the blood of 
those ill with the disease. It is not probable that 
infection is carried in clothing, ships, etc. Young 
infants and the aged are likely to escape. Whites are 
more susceptible to the contagion than negroes. Epi- 
demics cease after a frost, as the low temperature kills 
the mosquitoes. An individual who has suffered one 
attack is very unlikely to be infected a second time. 

Course and Symptoms. — The incubation period 
varies from three to six days. The invasion of the 
disease is extremely acute and marks the commence- 
ment of 



u6 



FEVER NURSING. 



The First Stage. — The onset is marked by chilly 
feelings or a convulsion, with rapid rise of temperature 
to 102° to 105 F. (38.9 to 40.5 C). With slight 



DAY OF 
DISEASE 


1 


2 


8 


4 


5 


6 


7 


8 


9 


10 


11 1 


2 13 


14 


15 














HOUR 


A 

M 


P 
M 


A F 

M N 


A P 

M M 


A P 

M M 


A F 
M Ik 


A 
M 


P 
M 


A 
M 


P / 
M N 


p 

1 M 


A P 

M M 


A P / 

M M 


P A 

A M M 


P A 
M M 


P 

M 


A 
M R 


3 A 
1 M l\ 


I 
















107 




























































































































































:r42 










































































































106 








































































































:3 






























































































































































•* 105 








































































































: "41 




























































































































































:q 


• -a 
8 104 






























































































































































% 






1 












































-1 a 




* 




- Ct 




| 








































;j ,„os 


03 

a 103 




\ 




-i^4 


A 


' 


j 






































:— 40 g 








-3^ 


r" 










































-i £3 








.at 




| 








































:a w 








: t 


1 1 


\/ 














































: t 


/ 


V 








































-Z m 


8 102' 










v 










































"- S 
















fl 




































-- K 
















\ 




































H 














-M 






































: ~qq° S 


SS 

H 101 




















































:- g 






























































































































































1 ; 

H 100 
















































































































































































































- 38 -• 




















































. ,°° <w 


99 






























































































































\ 






























0. 






















\ 




















































\ 
























































V* 




























- - 


W 




















































:^37 






















































97 






































































































































































































































































96 




















































- - _o 




















































:■— 00 










































































































,150 










































































































140 










































































































130 










































































































120 










































































































m 110 


•- 


\ 




















































\ 


















































S iOO 


























































k 
















































* 90 






\ 






















































L 








A. 






































80 








> . 






/ 














































t'^ 






r^ 




s 




































70 










"*»,/ 


\ 


/ 






w* 1 






















































































60 










































































































60 










































































































40 











































































































Clinical Chart of a Yellow Fever Patient showing the pulse typi- 
cally slow in comparison to the height of the temperature. 

variations the fever lasts from three to four days, fall- 
ing by lysis. There are severe headache and general 
pains, sore-throat, vomiting, restlessness and great 



INFECTIONS OF CONTINUED TYPE. "7 

prostration. The face is flushed, the eyes reddened 
and watery, and there is dread of bright light. The 
pulse is weak and slow in proportion to the height of 
the temperature, and may become slower than normal 
before the fever declines. The tongue is red and dry 
and the gums are sore. The patient vomits, first the 
contents of the stomach, and then mucus, bile and 
blood. The bowels are usually constipated, but the 
stools are not light in color. The urine is scanty, high- 
colored, and usually contains albumin. About the 
second or third day the whites of the eyes become yel- 
lowish, and later jaundice appears over the entire 
surface of the body. 

The Second, or Stage of Calm, appears when the 
fever declines ; the symptoms gradually disappear, and 
the patient goes on to recovery, or, after a period last- 
ing from a few hours to a day or two, he becomes 
worse and goes on to 

The Third Stage, which is marked by extreme pros- 
tration, normal or elevated temperature, soft and very 
slow pulse, and haemorrhages. Bleeding into the stom- 
ach and the vomiting of the partly decomposed blood 
(black vomit) occurs, and tarry stools may be observed. 
Haemorrhages from the nose, gums, uterus and kidneys 
and into the skin are not infrequent. The jaundice 
persists, and there may be suppression of urine, fol- 
lowed by convulsions and death due to uraemia. 

If the patient recovers the symptoms slowly amelio- 
rate, and prolonged convalescence takes place. 

Complications and relapses are rare. 



n8 FEVER NURSING. 

The disease may vary from the regular type and be 
very mild, lasting but two or three days, and showing 
none of the usual symptoms ; or it may be malignant, 
with little or no rise in temperature and early stupor 
or coma, followed in three or four days by death. 

Prevention. — Quarantine, in the light of present 
knowledge of the method of transmission of yellow 
fever, seems unnecessary, but as a precaution it is best 
to isolate the patient. 

Prevention consists chiefly in protection from and 
destruction of the mosquitoes. How effectually this 
prevents the disease is evidenced by its rarity in Ha- 
vana since proper steps have been taken in this direc- 
tion. Mosquitoes may be destroyed by sulphur fumi- 
gation in dwellings and prevented from entering by 
screens. 

Patients suffering from the disease should be sur- 
rounded by netting. Curative and preventive inocula- 
tion by various serums appears to be of little use. Even 
though it seems improbable that yellow fever can be 
transmitted by means of clothing and the like, it is 
wise to disinfect the patient's apartment and all articles 
with which he has come in contact according to the 
methods employed after smallpox and the other infec- 
tious diseases. 

Treatment. — The patient should not be moved after 
the onset of the disease, and strictest quiet must be 
enjoined. If he cannot urinate while lying in bed he 
must be catheterized. All body and bed linen must be 
changed with the utmost care to disturb the patient to 
the least possible degree. 



INFECTIONS OF CONTINUED TYPE. 119 

The symptoms should be treated as they arise. 
During the active stage all medicine must be given 
per rectum or hypodermatically ; never by the mouth. 
For the vomiting, cracked ice may be given, and a 
mustard plaster or hot poultice applied to the upper 
abdomen. No purgatives should be given. Suppres- 
sion of the urine may sometimes be relieved by hot 
packs over the region of the bladder, high rectal ene- 
mata of normal salt solution, and alkaline diuretics. 
The haemorrhages are difficult of control. 

Diet. — During the acute stage all food should be 
given per rectum ; during convalescence the greatest 
caution is to be observed in feeding, for solids given 
too soon are likely to provoke haemorrhage. No solids 
should be given for at least ten days after the symp- 
toms have subsided. At first the patient may have 
peptonized milk or kumyss, a drachm every half hour, 
then beef juice may be allowed; also whites of eggs 
and infant foods, broths and gruels. Gradually may 
be added the various semi-solids, junket, cereals, etc., 
and so on till the patient is strong enough to tolerate 
solid diet. 

The nursing of yellow fever requires no other in- 
structions than those given in the chapter on fever 
nursing in general. 

Influenza. 
Synonyms. — Epidemic Catarrhal Fever; La Grippe. 
Definition. — An epidemic febrile disease character- 
ized by catarrhal inflammations of the various mucous 



120 FEVER NURSING. 

membranes, prostration, and a tendency to involvement 
of the digestive and nervous systems. Influenza occurs 
from time to time in wide-spread epidemics. 

Causation. — The disease is more common and severe 
in adults than in children, and though it prevails at 
all seasons, it is more fatal in the colder months. 
Bad sanitary surroundings do not seem to affect its 
incidence, and persons who have suffered from the dis- 
ease seem more prone to contract it than others. The 
specific cause is a bacillus which is found in the exuda- 
tions from the inflamed mucous membranes (especially 
in the nasal discharge and sputum) and in the blood. 

Course and Symptoms. — The incubation period is 
from a few hours to several days ; the onset is sudden, 
with a chill followed by a rise in temperature (ioi° to 
104 F. — 38.4 to 40 C), severe headache, and mus- 
cular pains; there may be nausea and vomiting, to- 
gether with the other symptoms usual in commencing 
febrile disease. The fever lasts from two to six days 
and may be of remittent or intermittent type ; the pulse 
is rapid, and in old persons may be feeble. During the 
course of the disease various skin eruptions may 
appear. As the temperature approaches normal, sweat- 
ing is likely to occur, and the symptoms then gradually 
subside. 

The disease manifests itself in one of three main 
types, which are very likely to merge into one another. 

The Catarrhal Type is characterized by symptoms 
referable to the mucous membranes of the respiratory 
tract and conjunctivae. There are sneezing, nasal dis- 



INFECTIONS OF CONTINUED TYPE. 121 

charge, a feeling of fulness in the head, sore-throat, 
and hoarseness, and the eyes are congested. The 
cough is at first dry, but soon muco-purulent sputum 
appears; rarely it may be blood-stained. Bronchitis 
and pneumonia of severe form are not infrequent 
complications. Recovery is slow, and the cough may 
persist for weeks. 

The Nervous Type begins with severe headache, 
ringing in the ears, general muscular pains, and ex- 
treme depression and prostration; rarely convulsions 
occur. In some cases there are symptoms resem- 
bling those of meningitis, such as sensitiveness to light 
and sound, pain in the back of the head, and stiffness 
of the muscles of the neck. Delirium sometimes is 
seen. The nervous symptoms gradually subside in the 
course of a few days, but during convalescence there 
is a marked tendency to mental depression and neu- 
ralgia in various parts of the body. True neuritis is a 
frequent sequel. 

The Gastro-intestinal Type is evidenced by vomiting, 
cramps in the abdomen, distention and diarrhoea; the 
symptoms may be so severe as to suggest peritonitis or 
appendicitis. Jaundice may be present. 

Complications. — The most common of these are 
bronchitis, pneumonia, which is usually of severe char- 
acter, and neuritis. Various other complications, such 
as pleurisy, inflammations of the heart and pericar- 
dium, conjunctivitis and otitis, are less frequent. 

Influenza in old persons or those previously weak- 
ened by disease is always serious and often fatal. 



122 FEVER NURSING. 

Prevention. — During epidemics it is wise to avoid 
undue exposure to cold and wet, and to keep the body 
in as hygienic a condition as possible. If there is any 
tendency to nasal or throat inflammation the daily use 
of an antiseptic spray is advisable. 

Quarantine of patients suffering from the disease is 
hardly necessary, but all needless association with suf- 
ferers is to be avoided. 

Treatment. — At the onset the patient should go to 
bed, and an attempt may be made to shorten the dis- 
ease by means of free opening of the bowels and the 
induction of sweating by the administration of a hot 
pack and hot drinks. 

If the disease continues despite these measures, 
treatment calculated to relieve the symptoms should be 
undertaken. The pains may be controlled by hot or 
cold applications and the administration of acetphene- 
tidin (phenacetin) when ordered by the physician; 
the nose and throat inflammations should be treated 
with antiseptic sprays or applications. In cases with 
marked prostration heavy stimulation may be neces- 
sary. 

The Diet during the febrile stage should be of 
fluids, and it is very important that the patient's nutri- 
tion be maintained. As convalescence begins, semi- 
solids may be allowed, with solids to follow as soon as 
they are tolerated; the patient should be encouraged 
to eat as much as he can assimilate. Various tonics 
such as malt extracts, fat emulsions, and cod-liver oil 
are useful at this juncture. 



INFECTIONS OF CONTINUED TYPE. 123 

In nursing there need be no departure from the 
usual principles. 

Malta Fever. 

Synonyms. — Mediterranean Fever ; Neapolitan 
Fever; Rock Fever; Undulant Fever. 

Definition. — An infectious fever characterized by 
an irregular temperature, sweats, diffuse pains, and a 
tendency to relapse. 

Causation. — The disease is endemic in Malta, and 
epidemics occur from time to time in the countries 
bordering on the Mediterranean ; it is occasionally seen 
in tropical America. It attacks young adults most 
frequently and prevails chiefly in summer and under 
unhygienic environments. Its specific cause is the 
bacillus melitensis, which is believed to enter the body 
in the inspired air. 

Course and Symptoms. — The incubation period 
lasts from a few days to two weeks. The invasion 
is slow, with headache, restlessness, prostration, consti- 
pation, and sometimes bloody stools. The temper- 
ature becomes elevated and the spleen enlarged. The 
temperature, after remaining high for from one to 
four weeks, falls to normal and remains there for a 
period of from one to three days, when a relapse, 
often of a more severe character than the first attack, 
takes place. The symptoms are increased in severity, 
the temperature, though intermittent, is high, and there 
may be delirium and diarrhoea. These symptoms may 
last five or six weeks. A second temporary convales- 



124 FEVER NURSING. 

cence is followed by a second relapse, in which severe 
joint pains are usually present. After the second 
relapse the patient may go on to recovery, or a third 
relapse may ensue after an afebrile period lasting 
several months. The mortality is not great, death 
when it takes place being due to the continued high 
temperature or to exhaustion. 

Complications. — Broncho-pneumonia and pleurisy 
sometimes occur; arthritis and orchitis are more rare. 

Prevention consists in avoidance of the localities 
in which the disease prevails. So far as we are at 
present aware, little else can be done in this regard. 

Treatment is stimulative and supportive. High 
temperature may be controlled by bathing, the joint 
pains by applications of heat or cold. 

Diet. — The diet applicable to typhoid fever is suit- 
able in this disease. 

The nursing is to be carried out along the usual 
lines. 

Mountain Fever. 

Synonyms. — Spotted Fever ; Tick Fever. 

Definition. — An acute infectious disease character- 
ized by a typical skin eruption, recurring chills, and 
high fever. 

Causation. — The disease occurs in the Rocky Moun- 
tain regions of Idaho and Montana. It attacks all 
ages and both sexes, and is most frequently observed 
during the months from March to July. Its specific 
cause is a microorganism resembling that of malaria, 
which is conveyed to the patient through the bite of a 



INFECTIONS OF CONTINUED TYPE. 125 

certain form of tick. This organism exists in moder- 
ate numbers in the blood of patients suffering from the 
disease. 

Course and Symptoms. — The period of incubation 
is from three to ten days. The period of invasion is 
marked by malaise ; the onset by a distinct chill (which 
recurs at intervals during the disease, though decreas- 
ing in severity), headache, pains in the bones, and pros- 
tration. The initial chill is followed by a rapid rise in 
temperature, which by the second day reaches 103 or 
104 F. (39.5° to 40 C). It gradually increases to a 
maximum of 105 to 107 F. (40.5 to4i.6° C), from 
the fifth to the seventh day. The temperature is high- 
est at night, being slightly lower in the morning. 
About the middle of the second week the fever begins 
to fall by lysis, reaching normal on the fourteenth day. 
In fatal cases the temperature may fall to normal, or 
below, a few hours before death. The bowels are usually 
constipated; there is often a bronchial cough. The 
tongue and facial expression resemble those of typhoid 
fever, and in severe types of the infection nervous 
symptoms resembling those of that disease are to be 
expected. 

The pulse at the onset is full and strong, becoming 
rapid and weak as the severity of the disease increases. 
The appetite during the first week of the disease is 
often good. At the beginning of the second week 
nausea and vomiting appear and in fatal cases may 
continue. The spleen is enlarged. The respiration 
is rapid and regular, but shallow. It may reach 60 
but is usually about 40. 



126 FEVER NURSING. 

As a rule the prognosis is good, with proper care. 

The eruption appears on the second to the fifth day, 
first upon the wrists, ankles or back. Thence it 
spreads, covering the whole body. It may progress so 
rapidly as to cover all the skin in twelve hours, but 
usually the height of the eruption is reached in one or 
two days. The rash is frequently present upon the 
scalp, palms and soles. It at first consists of rose- 
colored, circular spots, from the size of a pinhead (two 
to four millimetres) to that of a small pea. They are 
not elevated and in the beginning disappear on pres- 
sure ; they may be tender to the touch. They quickly 
become permanent and dark-blue or purplish in color, 
and they increase in size until the skin assumes a mar- 
bled appearance. Sometimes the eruption consists of 
small brownish spots which give a speckled appearance 
to the skin. 

Desquamation begins during the third week, and as 
the fever falls the spots fade, but may not wholly dis- 
appear for weeks or months. There is usually jaun- 
dice. The skin may become gangrenous over the 
elbows, fingers, toes or scrotum. 

Prevention. — The districts in which the disease 
occurs should be avoided during those months in which 
mountain fever is prevalent. Measures should be 
taken to avoid tick-bites, but when these are received 
the insect should be removed at once by the application 
of turpentine, ammonia or kerosene, and the wound 
cauterized with pure phenol (carbolic acid). 

Treatment. — The use of quinine in large doses 



INFECTIONS OF CONTINUED TYPE. 127 

hypodermically has given favorable results in the 
few cases in which it has been employed. Otherwise 
the treatment of the disease is purely symptomatic. 

The Diet and nursing suitable to typhoid fever may 
be employed with advantage in mountain fever. 

Acute Miliary Tuberculosis. 

Synonyms. — Acute Tuberculosis : Acute General 
Tuberculosis. 

Definition. — An acute febrile disease characterized 
by the formation of miliary tubercles in various organs 
of the body and accompanied by constitutional symp- 
toms closely resembling those of typhoid fever. 

Causation. — Acute tuberculosis may follow localized 
tuberculosis of the lungs, bones, joints or glands, or 
occur in individuals in whom tuberculosis in any form 
has not been previously recognized; although it is 
probable that these patients have had undemonstrated 
tuberculosis of some organ or tissue. The specific 
cause of the disease is the tubercle bacillus, which in 
some manner has entered the circulating blood in 
considerable number and has been deposited in the 
various organs by means of this medium. 

Course and Symptoms. — The disease resembles 
typhoid fever to so marked an extent that differentia- 
tion may be very difficult. The onset is slow, with in- 
creasing weakness, headache, nausea, constipation and 
fever. The temperature is irregular, being low in the 
morning and high at night (102 to 105 F. — 38.9 



128 FEVER NURSING. 

to 40.5 ° C), and is accompanied by sweating; the 
pulse is rapid (140 to 150) and the respirations are 
accelerated (36 to 70) ; there may be blueness of the 
lips and extremities. Cough is usually present; the 
sputum is scanty and mucoid, and may or not contain 
the bacilli. Fever sores upon the lips are not rare. 
Otherwise the symptoms so resemble those of typhoid 
fever as to need no further description in a work of 
this character. The disease is invariably fatal. 

Varieties. — There are several varieties of the in- 
fection : 

(a) The Typhoid Type, in which many of the ner- 
vous symptoms of typhoid fever are present. 

(b) The Menningeal Type, in which there are 
hyper-sensitiveness of all the senses, convulsions, stiff- 
ness and pain in the back of the neck, and finally coma 
with paralyses. 

(c) The Pulmonary Type, which is characterized by 
distressing cough, extreme shortness of breath, and 
blueness of the lips and extremities. 

(d) The Abdominal Type, in which there are dis- 
tention and tenderness of the abdomen. 

Treatment is entirely symptomatic. The high fever 
may be controlled by bathing, the heart-weakness 
combated by stimulants, and the cough and nervous 
symptoms relieved by sedatives. Otherwise the treat- 
ment of the symptoms of typhoid fever is applicable. 

The Diet and nursing should also be based upon the 
principles already described for typhoid fever. 



INFECTIONS OF CONTINUED TYPE. 129 

Chronic Pulmonary Tuberculosis. 

Synonyms. — Chronic Phthisis; Consumption. 

Definition. — A chronic disease characterized by pro- 
gressive emaciation, obstinate cough with the expec- 
toration of muco-purulent matter and sometimes of 
blood, fever and night-sweats. 

Causation. — The disease is predisposed to by an 
hereditary tendency, by unhygienic methods of life, 
and by unhealthful surroundings. Its specific cause 
is the tubercle bacillus, which reaches, either through 
the blood stream or upon the inspired air, the interior 
of the lungs and there causes a tuberculous inflamma- 
tion. 

Course and Symptoms. — Sometimes the disease 
gives few recognized symptoms until the inflammation 
in the lungs has made considerable progress, but 
usually the patient becomes aware that his condition is 
not as it should be by the appearance of persistent 
cough, of pulmonary haemorrhage, of progressive loss 
of flesh and strength, of chilly and feverish feelings, 
or of night-sweats. 

The temperature of the disease is not constant; it 
may remain normal for considerable periods, but usu- 
ally it shows a remittent curve, being about ioo° F. 
(37.8 C.) in the morning and rising in the afternoon 
to 102 or 103 F. (38.9 to 39.5 C.) ; with the fever 
there are chills and sweats, clammy perspiration at 
night being a feature of the disease. 

The pulse is moderately increased in rate, and as 
the prostration increases becomes progressively more 
10 



13° FEVER NURSING. 

feeble; both pulse and respiration are quickened by 
slight exertion. Usually the respiration, even when 
quiet, is faster than normal, but the patient seldom 
complains of shortness of breath. 

As the disease goes on the patient gradually loses 
flesh, his cheeks become sunken and flushed (the 
"hectic flush"); the color of the skin is otherwise 
pale or it may be bluish over the extremities; the 
spaces above and below the clavicles are sunken, the 
ribs are prominent, and the abdomen hollowed. 

The appetite is poor, the tongue is coated, and there 
may be nausea and vomiting caused by the swallowed 
sputum. Late in the disease there is likely to be diar- 
rhoea, due to a complicating tuberculous inflammation 
of the intestinal lining. 

The cough may be dry, or there may be muco-puru- 
lent sputum in greater or less amount. A consider- 
able quantity of purulent sputum may be raised upon 
the occasion of the rupture of an abscess in the tissues 
of the lung. The sputum may be streaked with blood 
and at times haemorrhages may take place, not rarely 
so profuse as to end in death. The sputum contains 
the tubercle bacilli in greater or less number. 

There may be pain in the chest due to a complicating 
pleurisy. 

Tuberculous laryngitis, accompanied by hoarseness, 
a laryngeal cough, and pain and difficulty in swallow- 
ing, is a common complication. 

In women menstruation is irregular or stops entirely. 

A feature of the disease is the fact that the patient is 



INFECTIONS OF CONTINUED TYPE. 13 1 

cheerful, and no matter how ill he may be is very hope- 
ful of recovery. 

Prevention. — Persons with an inherited tuberculous 
tendency should be careful to avoid exposure to cold 
and wet, and endeavor to lead as healthful lives as 
possible. 

Since the sputum of this disease contains the tubercle 
bacilli, the greatest care should be exercised in its 
disposal. Indoors, it should always be expectorated 
into paper cups, which may afterward be burned, or 
into vessels containing a disinfectant solution (1 to 10 
phenol (carbolic acid) solution or 1 to 2000 mercury bi- 
chloride), and when the patient is out of doors he should 
be provided with an appropriate pocket flask. If cloths 
should be used they must be burned as soon as possible. 
Great care should be taken by the patient to prevent 
the hands, face and clothing from becoming contami- 
nated by the matter coughed up. If they do become 
soiled they should be washed at once with soap and 
hot water. By coughing or sneezing, particles of 
moisture are expelled which may contain the bacilli; 
consequently a cloth, which must subsequently be 
burned, should be held before the mouth during these 
acts. Male patients should always keep the face 
cleanly shaven. 

All the patient's personal and bed linen should be 
handled as little as possible when soiled, and should 
be placed in water until ready for washing. His apart- 
ment should be subjected to periodical disinfection by 
one of the usual methods. 



132 FEVER NURSING. 

When the patient is too weak to properly dispose of 
his sputum, all utensils and clothing which become con- 
taminated must be cared for as described in the chap- 
ter upon disinfection, and rooms which have been occu- 
pied by tuberculous patients should be fumigated by 
the processes usual after the infectious diseases. 

The stools of patients with tuberculous disease of the 
intestine may also contain the bacillus, and these, as 
well as all articles contaminated by them, should be 
disposed of as set forth in Chapter IV. 

Attendants should avoid standing in front of the 
patient when he coughs, for minute particles of spu- 
tum containing the bacilli may by this act be projected 
into the atmosphere and infect those with whom they 
come into contact. 

Treatment. — The main object in the treatment of 
this disease is to improve the general nutrition. The 
patient's apartment should be large, airy, and sunny, 
and without carpet or draperies. He should spend as 
much time as possible in the outdoor air (if possible 
living and sleeping there) ; in bad weather being prop- 
erly sheltered and wrapped during his airing. At 
night the room should be freely ventilated, no matter 
how cold the weather; but avoidance of draughts is 
necessary. He must be well supplied with extra-warm 
clothing and blankets. 

Exercise in moderation, but not when it tires the 
patient nor when fever is present, may be indulged in. 
When the disease is advancing rapidly, when there is 
marked fever, and when complications arise, he should 
be kept in bed. 



INFECTIONS OF CONTINUED TYPE. 133 

When in the open air the patient should periodically 
draw several long breaths through the nose, so as to 
thoroughly aerate the lungs. A sponge bath with 
water at a moderate temperature should be given daily. 
The underclothing should be of wool and of moderate 
weight. Pajamas of flannel are to be preferred to the 
ordinary night gown. 

The drugs most used in the treatment of this disease 
are cod-liver oil and creosote or some of its derivatives. 
Creosote is frequently given by inhalations from a 
mask made of perforated metal, which may be worn 
as long as desired. The appliance contains a sponge 
which is moistened with a mixture of equal parts of 
creosote, chloroform and alcohol. Tonics are often 
useful. 

The night-sweats may be controlled by the adminis- 
tration of various drugs, or by waking the patient 
about four o'clock in the morning and giving him a 
glass of warm milk containing a little whiskey. This 
procedure possesses the additional benefit of supplying 
a little extra food. 

If the sputum is foul the inhalation of the vapor of a 
few drachms of turpentine added to a kettle of steam- 
ing water is beneficial. 

Pulmonary hemorrhage should be treated by insist- 
ing upon absolute quiet in bed and the application of 
an ice-bag to the chest. 

The internal administration of calcium chloride and 
suprarenal extract and subcutaneous injections of 
gelatin solution have been advocated. No medica* 



134 FEVER NURSING. 

tion, however, should be administered unless ordered 
by the physician. 

For patients able to travel a change of climate is 
frequently beneficial. A climate which agrees with the 
patient should be chosen. Some do best upon the sea- 
shore, others at high altitudes. There is no way of 
determining in advance whether or not a certain cli- 
mate will prove beneficial. 

The Diet in chronic phthisis is a most important 
consideration. The secret of feeding tuberculous 
patients is to give them light, nutritious, easily digested 
food, and to feed them early and often. The patient 
should have at least three hours in which to digest the 
heavier meals, so that the stomach may be emptied 
before the next feeding. About seven o'clock in the 
morning he should be given a glass of warm milk 
containing a tablespoonful of strong French coffee. If 
the previous night has been an exhausting one, whiskey 
may be substituted for the coffee. Before being added 
to the milk, the spirit should be diluted with an ounce 
of water, lest it cause coagulation and render the mix- 
ture indigestible. Breakfast should be taken about 
nine o'clock, and may consist of eggs cooked in any 
way except by frying. If the patient insists upon hav- 
ing fried eggs, olive oil or butter must be used instead 
of lard. Bread, toast or cold rolls with butter, milk 
and coffee may complete the meal. 

About eleven o'clock the patient is to receive a second 
breakfast consisting of a cup of cocoa from which the 
fat has been extracted, or coffee, with bread and a little 



INFECTIONS OF CONTINUED TYPE. 135 

soup or beef extract. An eggnog is permissible and 
kumyss or matzoon is often acceptable. 

The dinner should be served about one o'clock and 
may include any kind of fresh meat, though this must 
not be fried. Potatoes, fresh vegetables, fruits and 
puddings may also be allowed. Coffee, tea or possibly 
a bottle of light beer may be added. 

About four in the afternoon the patient should take 
a little meat-extract with toast, and about five o'clock 
a little more should be given. About seven o'clock in 
the evening comes supper, consisting chiefly of farina- 
ceous food, with the addition of various jellies, beef 
extracts and gruels. If the patient is awake at eleven, 
a cup of milk, hot soup, or gruel may induce sleep. 

Patients, whose temperature rises in the afternoon 
should usually take no alcohol after the one o'clock 
meal. In other cases the only alcohol permissible in 
the afternoon is light beer, or possibly stout at bed 
time. 

Especially in patients with complicating tuberculous 
laryngitis, and in others when indicated, forced feed- 
ing by gavage (Debove) accomplishes good results. 
For this procedure the food is prepared as follows: 
Lean meat from which all the gristle and tendon and 
much of the fat have been removed should be used. 
The meat should be chopped fine and dried in an oven 
at 150 F. (65.6 C). To insure absolute dryness the 
temperature of the oven is then gradually raised to 
about 170 F. (76.7 C). When the meat has thus 
been thoroughly dried, which takes a number of hours, 



I3 6 FEVER NURSING. 

it should be ground in a mortar and sifted. Six pounds 
of raw beef treated in this way furnish about one pound 
of the beef powder. In administering the food a 
stomach tube (not a stomach pump) is used. This 
tube should be of soft rubber, of three-eighths to one- 
half an inch outside diameter, and with an opening 
both at the side and at the extremity of its tip; a 
glass funnel should be attached to the other extremity. 
At about sixteen inches from the tip of the tube there 
should be a mark, so that we may know when the 
stomach has been reached. 

Before passing the tube it should be lubricated by 
pouring upon it a few drops of glycerin, which should 
be allowed to run down its outside to the tip. Then, 
grasping the appliance between thumb and forefinger 
at about six inches from its tip, the nurse should stand 
directly in front of the patient, and as the mouth is 
opened pass the tube along the dorsum of the tongue. 
When the tip reaches the back of the throat the nurse 
should rotate it and tell the patient to swallow. As he 
does this the tube should be quickly and gently passed 
down the oesophagus until it reaches the cardiac end of 
the stomach; as the tube passes this point a distinct 
sensation is perceived by the nurse. Care should be 
taken that the appliance is not passed into the trachea, 
instead of into the oesophagus. If this accident hap- 
pens air will be breathed through the tube, and the 
patient will experience difficulty in respiration. In the 
event of such an occurrence there is nothing to do but 
to withdraw the tube and begin over again. In pa- 



INFECTIONS OF CONTINUED TYPE. 13I 

tients with very sensitive throats it may be necessary 
to employ a spray of cocaine solution (four per cent.) 
or to administer bromides before the procedure. 

The tube being in the stomach, the organ should be 
washed, in order to cleanse its walls of mucus, by pour- 
ing in a pint of artificial Vichy water. After washing, 
the Vichy should be withdrawn by lowering the fun- 
nel, when the wash water will flow out by siphonage. 
The stomach having been washed, the nurse should 
proceed with the feeding of the patient by pouring into 
the organ through the tube three-quarters of a pound of 
the beef powder, to which has been added three times 
as much milk (two-and-one-fourth pints). This is to 
be left in the stomach. At first such a meal should be 
given twice a day, and the amount then gradually in- 
creased until the patient takes from one to one-and-one- 
half pounds of the powder and four or five pints of 
milk per day. If there is trouble in digesting this, the 
milk should be omitted and a little diluted hydro- 
chloric acid added to the meat powder. In no case 
should the hydrochloric acid be used if milk forms a 
part of the feeding. 

In the late stages of chronic phthisis, when the 
patient's digestion will not permit the administration of 
solid food and weakness forbids feeding by gavage. 
we must have recourse to a diet consisting of milk, 
soups, gruels and the like. 

The nursing in other respects is to be conducted as 
usual in febrile diseases. 



CHAPTER VI. 

INFECTIONS OF CONTINUED TYPE WITE LOCAL 
MANIFESTATIONS. 

Pneumonia: Diphtheria: False Diphtheria: Acute Articular 
Rheumatism: Erysipelas: Septicaemia: Puerperal Fever: 
Pyaemia: Mumps: Bubonic Plague. 

Pneumonia. 

Synonyms. — Pneumonitis ; Fibrinous Pneumonia ; 
Croupous Pneumonia; Lung Fever. 

Definition. — Pneumonia is an acute infectious fever 
characterized by inflammation of the lungs. 

Causation. — The disease is common in all countries 
and occurs at all ages; it is particularly fatal in 
infancy, old age, and alcoholic subjects. It is most 
frequently seen in the cold and damp months. Ex- 
posure to cold and wet, alcoholic excess, previous 
catarrhal affections of the lungs, and disease of the 
heart predispose to the infection. During epidemics of 
influenza pneumonia is likely to be prevalent and at- 
tended with an increased mortality. Several attacks in 
the same person are not infrequent. 

Various bacteria are found in the sputa of pneumo- 
nia patients, the most common of which are the micro- 
coccus lanceolatus, or diplococcus of Frankel, the ba- 
cillus pneumonic? of Friedlander, and ordinary staphy- 
lococci and streptococci. It is probable that pneu- 
monia is in a sense infectious, for although physicians 

138 



INFECTIONS WITH LOCAL MANIFESTATIONS, 139 

and nurses seldom contract the disease from association 
with patients, it is not uncommon for several cases to 
occur in the same house or to develop in a hospital ward 
after the admission of a patient suffering from the 
infection. The sputum probably is the means through 
which the contagium is carried. 

Course and Symptoms. — The incubation period is 
unknown, but in all probability is from a few hours to 
three days. The onset as a rule is sudden, with a 
marked chill followed by a rapid rise in temperature, 
sharp pain in the side, cough and shortness of breath ; 
the pulse is rapid and tense ; there is extreme prostra- 
tion. A frequent early symptom is herpes of the lips 
or nostrils. The cough is at first dry, but after two or 
three days a blood-stained expectoration appears (the 
so-called "rusty sputum"), which is so viscid that it 
adheres firmly to the sides of the containing vessel; 
in certain cases the sputum is not so viscid and pre- 
sents a dark brown color — " prune juice sputum." After 
the temperature has fallen the sputum becomes lumpy 
and yellowish or greenish in color. The pain in the 
chest is severe and knife-like in character, is usually 
felt in the axilla over the affected lung, and is increased 
upon breathing or coughing. It tends to become less 
marked as the disease progresses. The patient is likely 
to be more comfortable when lying upon the affected 
side, because in this position less motion of the in- 
volved lung is possible. 

The pulse is rapid and full at the onset of the dis- 
ease, but not so rapid as to retain the normal pulse- 



140 FEVER NURSING. 

respiration ratio; later it becomes weaker, irregular 
and perhaps dicrotic. There is always danger of heart- 
failure. 

The shortness of breath is a prominent symptom, 
and may be accompanied, especially in children, by 
movement of the nostrils. The respirations are shal- 
low and from thirty to fifty per minute — in children 
even more rapid. In some cases expiration is accom- 
panied by a grunting sound. Blueness of the lips and 
extremities may be present, with extreme respiratory 
difficulty. Nervous symptoms such as stupor and de- 
lirium are common. In alcoholic subjects delirium 
tremens is a frequent complication. 

The temperature reaches its highest point within a 
few hours after the onset and remains elevated, with 
slight morning remissions, until the crisis, which usu- 
ally takes place upon the seventh day, when it falls 
within a few hours to normal. With this occurrence 
the other symptoms abate. In children and old persons 
defervescence is more likely to take place by lysis, as is 
also the rule in cases protracted beyond the tenth day. 

Complications. — A dry pleurisy accompanies all 
cases of pneumonia in which the inflammation extends 
to the surface of the lung. Pleurisy with effusion is 
not infrequent, and may, especially in children, go 
on to empyema; in which latter case chills, sweating 
and a remittent temperature should lead us to suspect 
the presence of pus. 

Bronchitis may make the disease more severe and 
increase its exhausting effects. 



INFECTIONS WITH LOCAL MANIFESTATIONS. 141 

Pericarditis may occur and is due to an extension of 
the inflammation to the membranes surrounding the 
heart. 

Endocarditis is not rare. 

Jaundice may occur, especially in alcoholic subjects. 
With this complication the sputum may be tinged yel- 
low or green. 



Day OF -i o o 
DISEASE 1 2 d 


4 5 6 


7 8 9 


10 11 12 1 


3 14 15 16 17 1 


3 18 20 21 


HOUR A P A P A 
H0UK M M M M M 


P A P A P A P 


AIP A P A]P 
MM MM MM 


A P A P A,P A 
M M M M MM M 


p a|p aIpjaIp a<p A 

V. V M MM* M U M** « 


[P Aj,R A> AfP 

M MiM M W MM 
























- Z*f 












_ rv 






















| | . L_ _ i , 












1 — 1 — 1 — ' — 1 1 


[^ 2 














106 






1 




- 




































—41 


























•5 BEL : 












S 











H 


& ™. £ r : 










_ - - H 


filfii=--5-i 










°^ 


° -3^-^" 


j-S5- 








_ __ _4U J 




- ta 










§ lno? ■- »■ : 


:ct* 


J 






i - t? 


M Jc? 


ID- 


El 






_ i ► 




y- 


1 












II 






P 














a — -; 










*— E~39 w 


PU o - 












| M 










g== z t 


a -" 
























loo : 










Z -38 3 












Z- eu 




































- 
























_J 1 -& 












- 














07 - 












-ffi 


































- a«* 












-36 


96 
























15Q — 
























140 
























.18P 


-3 












Z E 










JW . »<*■-, ? 


!^ L S 












- S-J ^ 












- _¥ - 


^ _ 








j inn 




\ 








H W 




-^ mm 








e tn 




V23 








a* ^yu 




8- V 


■ 2» 












g« ^ 






..ffp 






\ 


















-ZQ... 




















































































«**. g 5 S3 


o oo o «b ao o 


sssss s 


f <f NO 







Clinical Chart of Acute Pneumonia showing pulse and respiration. 
Defervescence upon the seventh day of the disease. 



142 FEVER NURSING. 

Meningitis may exist as a complication, and is evi- 
denced by headache, stiffness of the neck, unequal 
pupils, and stupor or delirium. 

Varieties of the Disease. — Wandering Pneumonia 
is the term applied to that variety of the disease in 
which different areas in the lungs become successively 
inflamed. 

Typhoid Pneumonia has no connection with typhoid 
fever, but is the term applied to that type of the disease 
in which the patient is rapidly overcome by the 
toxaemia. The temperature may remain low, or it may 
reach a high level. The nervous symptoms are marked 
and the tendency to heart failure is great. 

Alcoholic Pneumonia occurs in individuals who use 
liquor to excess. It is typified by a severe course and 
a tendency to delirium tremens. It is very fatal. 

Pneumonia in Infants. — The onset may be marked 
by a convulsion. The temperature is irregular and 
usually falls by lysis. The mental symptoms are 
severe and, though there may be cough, there is usu- 
ally no expectoration, since if it be present at all it is 
apt to be swallowed. 

Pneumonia in Old Persons is characterized by a 
protracted course and moderate temperature, which as 
a rule falls by lysis; the prostration is extreme, the 
pulse is weak, the respiration shallow. This variety 
is usually fatal. 

Prevention. — All sputum should be disinfected, and 
after the disease is over the sick-room should be fumi- 
gated after the usual manner. 



INFECTIONS WITH LOCAL MANIFESTATIONS. 143 

Treatment. — The patient should be kept in bed and 
absolutely quiet, in a well- ventilated room at a tem- 
perature of about 70 F. (21. i° C). He should not 
be allowed to rise or to lift his head under any circum- 
stances. The bowels should be kept open throughout 
the course of the disease. 

A pneumonia jacket of cotton batting and oiled silk, 
fitted to the chest, may make the patient more com- 
fortable. Poultices or ice-bags applied to the inflamed 
lung do not influence the disease, but may relieve pain. 
The former may be made of kaolin cataplasm or flax- 
seed. The official kaolin cataplasm may be used by 
applying several turns of a three- or four-inch roller 
bandage to the chest, spreading the substance (pre- 
viously made hot in its container, care being taken 
that no water has gained access to it) in a thin layer 
upon that portion of the bandage which covers the 
affected portion of lung, and covering it with further 
turns of the bandage. 

A flex-seed poultice is made as follows: Bring a 
saucepan of water to the boiling point, and, without 
removing it from the fire, stir into it the meal little by 
little, until it has the proper consistency — about thick 
enough to be cut easily with a knife ; cook well and beat 
thoroughly until very light. The material thus pre- 
pared should be spread evenly, about one-fourth of an 
inch thick, upon a piece of muslin, previously cut to 
the desired size, leaving an inch or more of margin 
on three sides, and one end long enough to fold back 
as a cover, to be tucked over the end of the poultice. 



144 FEVER NURSING. 

The poultice should be carried to the patient between 
two hot plates, or on a board covered with a dish. 
It should be applied hot and covered with a piece of 
flannel or layer of cotton. Great care must be taken 
not to burn the patient. In renewing poultices it 
must be remembered that a surface to which continu- 
ous hot applications have been made will not bear a 
poultice so hot as that first applied. If the poultice 
cannot be applied immediately after it has been made 
it should be kept warm between two plates placed 
over a vessel of boiling water, not in the oven. 

The fever may be controlled by sponging with 
alcohol and water, and a luke-warm tub bath is an 
excellent measure in the case of children. 

Few drugs have any influence upon the course of the 
disease. The use of creosote carbonate, however, is 
frequently followed by beneficial results. It should be 
given only upon the physician's order. We endeavor 
to keep the pulse between ninety and one hundred, 
and of good strength. If this is done the respira- 
tion will be easier and the tendency to cyanosis dimin- 
ished. The drugs best suited to this purpose are 
alcohol and other cardiac stimulants. When the dys- 
pnoea is marked and the blueness of the lips and ex- 
tremities extreme, the administration of oxygen is 
valuable. It may be given continuously or at inter- 
vals, and in cases which it does not benefit it certainly 
does no harm. 

Treatment other than that described above should 
be calculated to relieve the various symptoms as they 
arise. 



INFECTIONS WITH LOCAL MANIFESTATIONS. 145 

After convalescence has begun the patient should be 
kept in bed for a week and given general tonic treat- 
ment. 

The Diet during the febrile stage should be entirely 
of fluids — milk, broths, gruels, etc., and should be 
administered either through a tube or by means of a 
cup with a spout adapted to the purpose. 

The nurse should above all things be quiet and care- 
fully observant of the slightest changes in the patient's 
condition. In this disease, as in few others, thoroughly 
efficient nursing is absolutely necessary. 

Diphtheria. 

Synonym. — Putrid Sore-throat. 

Definition. — Diphtheria is an acute infectious febrile 
disease, occurring sporadically and as an epidemic, and 
marked by inflammation, with the formation of a false 
membrane, in the upper air passages. 

Causation. — It occurs chiefly in children, is rare 
after sixteen years of age, and is most common in the 
colder months. The disease is predisposed to by the 
presence of adenoids and enlarged tonsils. It is of 
most frequent occurrence in unsanitary surroundings, 
in consequence of the fact that these cause general 
ill-health and lessen the resisting power of the body. 
The specific cause of the infection is the Klebs-Loeffler 
bacillus, which grows in the false membrane. The 
bacilli enter in the inspired air, upon substances con- 
veyed to the mouth, or by direct contact with an 
abraded surface; they are not borne upon sewer-gas 

ii 



146 . FEVER NURSING. 

or emanations from unclean drains, etc. The disease 
is very contagious for the distance of a few feet, but 
its poison is not very diffusible; consequently it is 
quite possible to confine it to a single room. The 
contagium may be carried long distances in clothing, 
etc., and may be transmitted by pet animals — cats in 
particular. Certain persons seem to be insusceptible 
to the infection, for the bacilli have been found in the 
throats of healthy individuals. Pieces of membrane 
coughed up by patients may infect physicians or nurses 
or be carried by them to a third person. In most 
cases the ordinary pus germs are found to co-exist 
with the Klebs-Loeffler bacilli. One attack seems to 
render the individual more susceptible to subsequent 
infection. 

Course and Symptoms. — The incubation period is 
usually from two to three days, rarely as long as a 
week; the onset is marked by chills or convulsions, 
followed by a rise in temperature to ioo° or 102 F. 
(37.8 to 38.9 C.) ; rarely, fever may be absent 
throughout the whole course of the disease. The 
throat is sore, swallowing is painful, and hoarseness 
due to laryngitis may be present; there are headache, 
pains in various other parts of the body, nausea, 
vomiting and prostration; the tongue is coated and 
the breath foul. The severity of the symptoms is 
usually in proportion to the extent of the local inflam- 
mation. The pulse is rapid and, throughout the dis- 
ease as well as during convalescence, there is great 
danger of heart-failure, which may be either very sud- 



INFECTIONS WITH LOCAL MANIFESTATIONS. U7 

den or gradual in its onset. Shortness of breath is 
common as a result of obstruction of the air-passages. 
The urine is scanty and high-colored, and often con- 
tains albumin and casts. 

The Malignant Variety. — Cases of this type ap- 
pear during every epidemic, usually in individuals 
whose condition is poor. Such cases are marked by 
prostration so severe that death may take place before 
the membrane appears; in other cases the membrane 
forms very rapidly. The febrile movement is absent, 
and there are extreme prostration and heart- weakness. 
The patient may become delirious or comatose, and 
death may supervene within a few days. 

The membrane may appear in any of the following 
situations : 

The Pharynx and Tonsils. — The tonsils and pharynx 
are red and swollen. Upon them are one or two small, 
grayish, membrane-like patches, which rapidly increase 
in size; the uvula becomes inflamed and sometimes 
oedematous; the glands in the neck become enlarged, 
but not tender. The membrane spreads over the back 
of the throat and is grayish or yellowish in color ; after 
about seven days it begins to disappear, and within a 
few days is entirely gone. With its disappearance the 
symptoms clear and convalescence begins. 

The Larynx. — When this part is involved the con- 
stitutional symptoms are similar to those described, 
with the addition of marked hoarseness, noisy breath- 
ing, and a croupy cough. In some cases the voice may 
be lost, and as the membrane spreads the difficulty in 



1 48 FEVER NURSING. 

breathing becomes extreme; the lips grow blue, and 
the patient's expression very anxious. Bits of mem- 
brane may be coughed up, but usually this gives no 
permanent relief, for new membrane soon forms. In 
severe cases of this type all the symptoms become accen- 
tuated, lung complications may occur, and death is not 
unusual. 

The Nose. — In nasal diphtheria there is a thin and 
sometimes very irritating discharge from the nostrils, 
which soon becomes brownish in color and may con- 
tain blood; the patient snuffles, sneezes and, if the 
nose is entirely occluded, breathes through the mouth. 
The inflammation may extend to the ears and eyes; 
the glands beneath the jaw are swollen. This type 
varies in severity, but as a rule is to be dreaded. 

The membrane may involve any two or all of the 
above situations. 

Complications. — Heart-failure is not rare and may 
cause the sudden death of the patient. Therefore the 
patient must not be allowed to sit up, to struggle, or 
to make any unnecessary exertion until convalescence 
has been thoroughly established. 

Nephritis of mild or severe character is not un- 
common. 

Pneumonia due to the inhalation of bits of mem- 
brane may occur. 

Paralyses are frequent sequels of diphtheria, and 
may appear even late in convalescence. They most 
usually affect the motor nerves supplying the muscles 
of the palate, the eye, the vocal cords, or the limbs. 
Such paralyses are seldom permanent. 



INFECTIONS WITH LOCAL MANIFESTATIONS. H9 

The diagnosis of the disease in poorly marked cases 
may be impossible without bacteriological examination ; 
consequently it is advisable that the nurse should be 
familiar with the technique of taking cultures from the 
throat. A culture outfit, consisting of a tube of solidi- 
fied blood serum and a swab encased in a sterile tube, 
is furnished for this purpose by the health boards of 
many cities. The patient should be placed in a good 
light and, if a child, firmly held. The swab should be 
rubbed against the suspicious area in the nose or throat 
by revolving it between the finger and thumb; then, 
care being taken that it does not come into contact 
with anything else, it should be gently rubbed over 
the surface of the serum in the culture tube; care 
should also be taken not to break the surface of the 
serum. The swab should then be returned to its tube, 
and both tubes stoppered with their cotton plugs. The 
culture is placed in an incubator for some hours, and 
finally examined microscopically. Throat cultures 
should not be taken directly after antiseptic applica- 
tions have been made to the inflamed surface. 

Preparation of a Room for a Patient Suffering 
from a Contagious Disease. — A bright sunny room, 
or two if possible, should be chosen at the top of the 
house, communicating with or near to a bath-room. 
Before removing the patient to the room, the nurse 
should prepare as follows: Remove all carpets, rugs, 
draperies, upholstered furniture, and pictures; retain- 
ing only the plainest and most necessary furniture. 
The following articles should be taken to the room: 



15° FEVER NURSING. 

Bedding (oldest), foot-tub for soaking clothes and 
bedding, bed-pan, commode and all other utensils for 
the sick, dishes, table linen, silver, dish-pan, clothing 
for patient and nurse, gowns, caps, and rubbers for 
physician or visitors, dust-pan, paper bags, pail, scrub- 
bing-brush, floor-cloths, gauze, soap, disinfectants, 
some kind of lubricant, mouth- wash, mouth-swabs, 
saucepan, gas stove or chafing dish. When the pa- 
tient is taken to the isolation room the nurse should 
remove with him the bedding, clothes, etc., which have 
been in use and are already infected. 

The general care of the patient while in isolation is 
as follows : The nurse should thoroughly wash and dis- 
infect her hands whenever she touches the patient or 
his bed, disinfect all linen, utensils, and secretions, keep 
the room clean, well ventilated, and the patient out of 
draughts, give the patient a daily bath and lubricate 
the skin, and see that his bowels move daily and that 
the normal amount of urine is voided. Fluids are to 
be given until otherwise ordered, and the mouth, teeth 
and tongue should be cleansed before and after each 
feeding. All dust and waste are to be put into paper 
bags and sent to be burned. The nurse must not allow 
flowers to be brought to the room, nor send anything 
from the room that has not been thoroughly disin- 
fected ; she must keep the door closed and not talk to 
persons outside with the door open. She should en- 
deavor to take a daily walk, but should not wear any- 
thing on the outside which has been in the sick-room. 

Prevention. — Since we know the • cause of diph- 



INFECTIONS WITH LOCAL MANIFESTATIONS. 15 1 

theria and its mode of transmission, we should be 
able to do much to prevent its spread. The following 
is a condensation of the rules concerning the disease 
laid down by the New York Health Department : 

If possible, one person should take entire charge of 
the patient and no one else except the physician should 
be allowed in the sick-room. The nurse should hold 
no communication with the rest of the family, who 
should not receive or make visits during the illness. 
Discharges from nose and mouth must be received on 
cloths which should be immediately immersed in car- 
bolic acid solution (six ounces of pure phenol — car- 
bolic acid — added to one gallon of hot water and this 
diluted with an equal quantity of water). All hand- 
kerchiefs, towels, bed linen, clothing, etc., that have 
come in contact with the patient, must after use be at 
once immersed, without removal from the room, in the 
above solution. They should be soaked for two or 
three hours, and then boiled in water for one hour. 

The greatest care should be taken in making appli- 
cations to the throat and nose, lest the discharges be 
coughed into the face or upon the clothing of the 
attendant. 

The hands of the attendant should always be disin- 
fected, by washing in the phenol solution and in soap- 
suds, after making applications and before eating. 

Surfaces of any kind soiled by discharges should 
be immediately flooded with phenol solution. 

All utensils used by the patient must be kept for his 
use alone; they must not be removed from the room, 



15 2 FEVER NURSING. 

but there washed in the phenol solution and in hot 
soapsuds. After use, the soapsuds should be thrown 
in the water-closet and the vessel which contained them 
washed in the phenol solution. 

The sick-room should be thoroughly aired two or 
three times a day and frequently swept, after scatter- 
ing wet sawdust on the floor to prevent the dust from 
rising. After sweeping, the room should be dusted 
with damp cloths. The sweepings should be burned 
and the cloths soaked in the phenol solution. 

When the disease is recognized shortly after the 
beginning of the illness, all hangings and unnecessary 
furniture should be removed from the sick-room. 

After recovery, the patient's body and hair should 
be washed with hot soapsuds, and he should be dressed 
in clean clothes, which have not been in the room 
during the illness, before being taken from the apart- 
ment. 

The quarantine should last as long as the diphtheria 
bacilli are found upon the mucous membranes; they 
may persist for six or eight weeks. 

The nurse and physician should wear, while in the 
sick-room, a gown which covers the clothing com- 
pletely. This should be kept just outside the apart- 
ment and sterilized directly after use. If the patient, 
while the throat is being examined, should cough in 
the examiner's face, the latter should wash the face 
and hair in soap and water, followed by I to iooo 
mercury bichloride solution. The hands must always 
be sterilized upon leaving the sick-room. The nurse 



INFECTIONS WITH LOCAL MANIFESTATIONS. 153 

should spray or gargle her throat several times a day 
with a mild antiseptic, such as the official antiseptic 
solution. 

It is strongly advisable that the nurse and the mem- 
bers of the family, if they have been exposed, should 
receive an immunizing dose (ioo to 500 or more units) 
of antitoxin, and at the first sign of sore-throat a full 
dose must be given. The effect of an immunizing 
dose lasts from two to four weeks, and at the close of 
this period a second dose should be given if there is 
continued exposure. 

After removal of the patient the room and its con- 
tents should be disinfected and aired in the manner 
described in Chapter IV. 

Treatment. — The patient should be kept in bed 
during the acute stage of the disease ; even in hospitals 
a separate room for each patient is to be preferred. 
If the disease is complicated by pneumonia the patient 
should be isolated under all circumstances. The apart- 
ment should be kept cool and freely ventilated. 

The treatment of diphtheria by antitoxin is attended 
with such good results that it is rapidly displacing all 
forms of drug treatment. The antitoxin, which is a 
yellowish transparent fluid, should be administered sub- 
cutaneously by means of an ordinary hypodermatic 
syringe which has been properly sterilized. The skin 
of the site selected for the injection, usually the thigh, 
the abdomen, or the side of the chest, should be bathed 
with soap and water and washed off with 1 to 5000 
mercury bichloride solution, and as soon as the injec- 



154 FEVER NURSING. 

tion is made the needle puncture should be covered 
with a bit of sterile gauze held in place by adhesive 
plaster. The quantity of antitoxin administered de- 
pends upon the age of the patient and the severity of 
the infection. The initial dose should usually be from 
iooo to 2000, or more, units — a unit being the quantity 
of antitoxin required to neutralize the amount of diph- 
theria poison necessary to kill one hundred small 
guinea-pigs. 

After the injection there is likely to be a slight local 
reaction — pain, tenderness, redness or oedema. Vari- 
ous skin eruptions may follow the administration of 
antitoxin, and these are sometimes accompanied by 
constitutional symptoms. Most commonly the rash 
appears upon the buttocks, abdomen or chest; there 
may be itching and occasionally there is desquamation. 

The drugs which seem to influence the disease most 
are mercury bichloride and the tincture of iron chlo- 
ride; they, especially the former, must be carefully 
given. The bowels should be kept open by supposi- 
tories of enemata; for the heart- weakness, whiskey 
and other cardiac stimulants may be necessary. 

Local Treatment is an important adjunct to anti- 
toxin, and should be employed even if the patient 
objects. Older children and adults may use sprays 
and gargles, but for young children irrigation is neces- 
sary. In employing this measure the child should be 
tightly wrapped in a sheet to prevent struggling, and 
laid upon a table, with its head low and the mouth 
directed toward the table edge, so that the fluid may 



INFECTIONS WITH LOCAL MANIFESTATIONS. 155 

run out and flow over a rubber sheet adjusted for the 
purpose, into a pail upon the floor. The irrigation 
tube is passed into the mouth (in which case the teeth 
should be kept separated by means of a cork) or the 
nose ; allowing the fluid to return through the nose or 
the mouth as the case may be. The irrigation should 
be made with some mild antiseptic solution, which is 
given lukewarm through a soft catheter attached to a 
fountain syringe. If the nose is entirely occluded, a 
passage for the catheter must be made along the floor 
of the nostril by means of a probe with a swab of 
cotton wrapped about its extremity. 

Irrigation does not reach the membranes in the 
larynx, and when the disease attacks this situation a 
tent should be made over the child by means of a 
blanket, and the tube of a croup-kettle inserted through 
an aperture. An improvised croup tent may be made 
by placing a screen or clothes-horse around the head 
of the bed. Over and around the screen pin blankets, 
allowing one-half of the top blanket to fall over the 
front of the screen, thus forming a tent over the head 
of the patient. Place a croup-kettle, or tea-kettle 
with a long spout, over a gas stove or alcohol lamp 
on a table at the head of the bed, where an opening 
should be left between the blankets just large enough 
to admit the spout of the kettle. Care must be taken 
not to have the fire too near the bed. An umbrella 
may be used for the tent by fastening it to the head of 
the bed and throwing a blanket over it in such a man- 
ner that the sides and back of the bed will be closed in, 



156 FEVER NURSING. 

while the steam is made to enter at the back. The 
spout of the kettle should be back of and out of reach 
of the child's hands. The inhalation of hot steam 
exerts a very beneficial action upon the inflammation, 
and a little turpentine or creosote added to the water 
in the kettle may increase the good effect. A marked 
laryngeal obstruction may be dislodged by a mild 
emetic, but this should never be employed in weak 
patients ; in their case the inhalation of calomel vapor 
may be substituted. This process is accomplished by 
closing the tent as tightly as possible and directing into 
it the vapor of ten to thirty grains of calomel burned 
upon a tin plate over a spirit lamp. 

If there is danger of suffocation from laryngeal ob- 
struction, either intubation or tracheotomy must be per- 
formed. The former consists in inserting a specially 
constructed tube into the larynx by means of an instru- 
ment made for the purpose. Attached to the tube is 
a cord to prevent its being lost in the oesophagus or 
trachea. When nursing a patient who has been in- 
tubated, care must be taken that the tube is not 
coughed up, and if it should be coughed up, that it 
does not become lodged in the oesophagus. The nurse 
should at once replace the tube if the physician is not 
accessible. When feeding the patient the nurse should 
raise the foot of the bed, as after intubation it is easier 
to swallow if the head is lower than the rest of the 
body. The intubation tube may be worn continuously 
for several days or extracted at intervals to be cleansed. 
In some cases it may be necessary to remove it at 



INFECTIONS WITH LOCAL MANIFESTATIONS. 157 

feeding time; other patients learn to eat with it in 
place. While wearing the tube the patient should be 
kept in a moist atmosphere and must be continuously 
watched lest the tube become plugged. 

Tracheotomy may be necessary if the obstruction 
extends to the trachea. The operation consists in 
making an opening into the trachea with a scalpel and 
inserting a specially constructed tube. After trache- 
otomy has been performed watch the patient very 
carefully and keep the opening of the tube covered 
with a layer of moist gauze to prevent dust, etc., being 
inhaled. If the patient should choke, remove the inner 
tube and cleanse with water by means of an applicator 
wrapped with cotton. If, after the tube is removed, 
the patient still chokes, pass a rubber catheter down 
into the trachea and blow through it to dislodge the 
mucus. 

The treatment of the complications is that usually 
employed in those conditions when they occur in other 
affections. 

The Diet should be chiefly of milk, and it must be 
given in sufficient quantity — three quarts a day being 
none too much for an adult. There is much more 
danger of under- than of over- feeding. Intubated 
patients can often swallow semi-solids more easily than 
liquids, and in such cases these may be allowed. In 
cases where swallowing causes coughing, and in intu- 
bated patients, feeding by gavage through the mouth 
or nose may be necessary. In nasal feeding the patient 
should either be lying down or sitting up with the 



i5 8 FEVER NURSING. 

head thrown back. A soft, well-oiled catheter is in- 
introduced through the nostril into the oesophagus for 
about fifteen inches and connected with a small funnel, 
into which the fluid food is poured. After the tube 
has been inserted the patient's color should be watched, 
and if he becomes cyanosed the tube should be with- 
drawn, as it is probable that it has gone into the tra- 
chea. Another accident that may happen, and must be 
guarded against, is the curling up of the tube in the 
mouth. When there is any difficulty in inserting the 
tube, it is well to try the other nostril, which may 
be larger on account of a deviated septum. When 
the tube once enters the oesophagus it is helped down 
by the constrictor muscles. Frequently, especially in 
intubated patients, feeding is best accomplished while 
the patient lies upon his back with his head well down. 
With regard to points other than those mentioned 
above the nursing should be conducted according to 
the ordinary rules. 

False Diphtheria. 

Synonyms. — < Pseudo-Diphtheria ; Membranous 
Croup. 

This is a disease which in appearance and symptoms 
resembles true diphtheria, but differs from it in causa- 
tion. It may complicate the infectious diseases or 
occur by itself ; the membrane does not show the pres- 
ence of the Klebs-Loeffler bacillus, but contains the 
ordinary pus germs (streptococci and staphylococci). 
Bacteriological examination is always necessary to dif- 



INFECTIONS WITH LOCAL MANIFESTATIONS. IS9 

ferentiate the two diseases. False diphtheria is usu- 
ally milder, shorter, and less likely to be followed by 
complications. 

The treatment, diet and nursing are the same as 
those applicable to true diphtheria, except that the ad- 
ministration of antitoxin is useless. Also, less strict 
quarantine and disinfection are required, although the 
possibility of transmitting the disease from one patient 
to another is not out of the question. 

Acute Articular Rheumatism. 

Synonyms. — Inflammatory Rheumatism; Rheumatic 
Fever. 

Definition. — An acute febrile disease, probably in- 
fectious, and characterized by inflammation of the 
joints. 

Causation. — A tendency to the disease may be 
inherited. It occurs chiefly in young adults and is 
more common in males than in females. It is predis- 
posed to by exposure to cold and wet, and by un- 
hygienic environment and mode of life. The specific 
germ of rheumatism has not yet been isolated, but 
it is probable that the disease is of infectious origin. 

Course and Symptoms. — The onset of the disease 
is usually sudden. The temperature rises rapidly and 
one or more of the joints becomes swollen, painful, 
reddened, hot and tender. The tongue is coated and 
the pharynx or tonsils may be inflamed. The joints 
involved most frequently are the knees, the wrists, the 
ankles, and the joints of the fingers. It is unusual for 



160 FEVER NURSING. 

the inflammation to be confined to a single joint, and 
frequently the process travels from one joint to an- 
other, one improving as another becomes affected. 
Sweating is a prominent feature of the disease. The 
reaction of the perspiration, as well as that of the 
saliva, is acid. The temperature ranges from ioo° to 
104 F. (37.8 to 40 C). The symptoms, unless 
the disease is treated, continue from one to three weeks 
— then gradually ameliorate. Relapses are frequent. 
When the inflammation proceeds from one joint to 
another the temperature rises, and the symptoms recur 
as fresh involvement takes place. 

Complications. — Hyperpyrexia is a grave compli- 
cation, and usually results in death. The tempera- 
ture may rise as high as no° or 112 F. (43.3 or 
44.4 C). Various eruptions are occasionally seen, 
and, especially in children, nodules {erythema nodo- 
sum) may appear over the tendons upon the back of 
the fingers, hands or wrists. Tonsillitis frequently oc- 
curs with rheumatism, and certain authorities believe 
that it results from the same cause. Inflammations of 
the heart and pericardium are very common, especially 
in young patients. Chorea is also very frequently seen. 

Prevention. — Persons predisposed to the disease 
should avoid exposing themselves to cold and wet, and 
during the cold months should wear woollen under- 
clothing. They should take moderate exercise and 
endeavor to keep the functions of digestion in proper 
condition. 

Treatment. — While the inflammation remains acute 



INFECTIONS WITH LOCAL MANIFESTATIONS. 161 

the patient should be kept in bed and warmly covered. 
When it becomes necessary to change his position he 
should be lifted; consequently a muscular nurse is 
an essential. The bowels should be kept open by 
saline laxatives. The drug which exercises the most 
beneficial influence over the disease is sodium sali- 



DAY OF 

(disease 


1 


2 


3 


4 


5 


6 


7 


5 


9 


10 


11 


12 


lo 


14 


u 


16 


17 


IS 


IS 


20 


21 


— 42 ' 


HOUR 




A,P 
MM 


A P 
M M 


MAI 


A F 
M M 


A ? 
M M 


A P 

M v. 


MP 


A,'P 
M M 


A P 


t 


? p 


A P 

M V 


A P 

'■'V 


hhp 


A P 

M V 


A t 

M M 


A P 

V. V 


a p 

M M 


A.f 


A' P 
U M 


107 
106 


" 


















































































































































































































































































































































































r 4l s 


105 


















































































































■ Sf 


»J — 




; ! , 


C104 






















— M 










1 1 ' ' 


: S 




























































1 | 






1 


t 




























P 103 




I 


f\ 






























±0 _: 

— 




J 


1 


























' 










\ 1 
























1 1 




: S 






M 


J 
































i n 
















A 






w_102j 








u i 
















*' / \ 




; 1 








y 
















Nf 1 


- 1! 






























/v 


) V 




1 ' 






- 




























































' \ 






^39 g 


'■A 

P 101 














































Jf l 






















. 


- " 

b 






































































3 loo 


























































































1 




1 




i 1 1 
























\\j 


































r» 99 






























A I 






























/ V 1 ; 


























v 1 ' 


















J)fl 










_+_ U \ — j — 1 — | — 




























i—4 — 1 — j — 1 — iy\j J 1 — 


_ fl 


























! 1 r ^ ,*>. - 


ST 


























1 .V \r 
































97° 






















































i ! I 1 
























































j i ! | j 1 j ' 
































96 


' 
























1 1 1 | 




























































j j 1 i 


1 






























1 1 1 1 1 1 1 


III 






1 — — 


1 — 1 — 




: 


















1,1 i ! . 


Mil 


— — 



Clinical Chart of Acute Articular Rheumatism showing renewal of 
the febrile movement consequent upon fresh joint involvement. 



cylate, given in large doses and in connection with 
the alkalies. Such medication should be given only 
upon the physician's prescription. 

The fever may be controlled by sponge baths; for 
the hyperpyrexia cold packs or tubs are required. In 
nursing, care must be taken when applying local appli- 



12 



162 FEVER NURSING. 

cations to move the affected joints very gently and 
as little as possible. Local applications of equal parts 
of guaiacol and glycerin, of oil of wintergreen, or of 
glycerin and the fluid extract of belladonna will do 
much to relieve the pain in the joints. The parts 
may be bandaged with flannel bandages and should be 
protected by " cradles" of barrel hoops from the 
weight of the bed-clothes. The patient should be 
moved as little as possible and never allowed to exert 
himself, in order to avoid unnecessary strain upon the 
heart. Further comfort may be obtained by wrapping 
the joints in cotton, and by the application of padded 
splints, sand bags, or small pillows adjusted about the 
inflamed limbs. The joints should always be placed 
in mid-flexion. Very severe pain may be mitigated by 
the application of blisters. Care must be taken not to 
jar the bed, nor to allow any sudden noise to startle 
the patient. During convalescence he should remain 
quiet and should avoid draughts. Too early return to 
meat diet is to be strongly advised against. 

Pericarditis or endocarditis may be controlled by 
the application of cold over the heart and by sedative 
drugs. 

The Diet during the febrile stage should be entirely 
of fluids. Milk and strained gruels may be given (no 
meat broths). During convalescence a gradual re- 
turn to a solid diet is permissible. The following 
articles may be given: vegetable soups, farinaceous 
puddings (without sugar), milk toast, and, later, fresh 
vegetables, fish, eggs and chicken. Other meats are 
usually withheld as long as possible. 



INFECTIONS WITH LOCAL MANIFESTATIONS. 163 

Alcoholic drinks and sweets are especially to be 
avoided. Saccharin may be used to sweeten the food. 

The nursing is to be carried on in accordance with 
the usual rules. 

Erysipelas. 

Synonym.— St. Anthony's Fire. 

Definition. — An acute, febrile, contagious disease, 
characterized by a chill, intense redness of localized 
areas of skin and mucous membrane, a remittent fever, 
and a tendency to recur. 

Causation. — The disease is met most frequently 
in the spring and autumn, and amid unhygienic sur- 
roundings. It attacks most commonly individuals ad- 
dicted to alcohol and others who are constitutionally 
weakened. It has been known to become endemic. 
Its specific cause is a germ known as the streptococcus 
erysipelatus, which enters the body through some 
abrasion of the skin or mucous membrane. The 
abrasion may be so small as to escape notice. 

Varieties. — There are various forms of this disease, 
but the more important are the following : 

(1) Cutaneous Erysipelas. — The onset is sudden, 
with a chill, fever and spots of redness on the skin. 
The fever is high and remittent and terminates on the 
fourth or fifth day, usually by crisis. In young per- 
sons the symptoms are, as a rule, slight, but erysipelas 
in infants, which is likely to follow infection of the 
umbilical cord, is generally fatal; in old persons the 
nervous symptoms may be marked, and death usually 
results. 



1 64 FEVER NURSING. 

The red spots tend to coalesce and to become 
slightly elevated. The margins of the infected area 
are sharply defined, red and swollen. As the disease 
progresses this area spreads, the color at the original 
site fading as fresh areas are involved (wandering 
erysipelas). The redness disappears on pressure, to 
return as soon as the pressure is removed. There is 
slight burning pain. Vesicles, which may become pus- 
tules, appear on the involved part. The eruption may 
vary in shade; it is usually bright or dark red in 
vigorous persons, dusky when pus is about to form, 
and blue when gangrene is about to appear or when 
there is involvement of the heart or lungs. When 
the inflammation ceases, the swelling and redness dis- 
appear and desquamation follows. 

(2) Phlegmonous Erysipelas. — The onset is marked 
by chills, sweats, high temperature (104 to 106 F. 
— 40 to 41. 1 ° C), delirium and severe prostration. 
The swelling is much more pronounced than in the 
preceding type, and may be so intense as to produce 
sloughing or gangrene. Suppuration generally takes 
place, extending into the tissues beneath, into the 
muscles, and even into their sheaths and those of the 
tendons. As the disease progresses, sloughs form and 
fall, leaving ulcers ; in some cases the muscles, tendons, 
etc., may be eaten away. This type of the disease 
sometimes follows extravasation of urine. 

(3) Cellulitis is that form of erysipelas in which the 
microbe has effected entrance through a wound. The 
swelling, which is not so marked as in the phlegmonous 



INFECTIONS WITH LOCAL MANIFESTATIONS. 165 

variety, appears before the redness, which latter symp- 
tom is not so pronounced as in the cutaneous form. 
The inflammation appears at the edge of the wound 
and does not leave the original focus as the disease 
extends. The poison, in mild cases, is disposed of by 
the lymphatic system, but severe cases are marked by 
suppuration in the wound and the adjacent lymph 
glands. 

Complications such as septicaemia, pyaemia, pneu- 
monia, meningitis and arthritis may arise. 

Treatment — The first step in all forms of the dis- 
ease is to isolate the patient; he should be kept in 
bed and the wound, if evident, should be thoroughly 
cleansed with antiseptics; the bowels should be kept 
freely open. In vigorous persons facial erysipelas re- 
quires but little treatment, but in weak and debilitated 
individuals free stimulation is necessary. High tem- 
perature may be controlled by cold bathing. An injec- 
tion of a two per cent, solution of phenol (carbolic 
acid) into the healthy skin just beyond the inflamed 
area, or a band of tincture of iodine painted upon 
the skin, may arrest the advance of the disease; 
scarification is sometimes practiced. Lead and opium 
wash, a ten per cent, solution of ichthyol in water, 
or an ichthyol ointment, will relieve the burning pain. 
In the phlegmonous variety the sloughs should be cut 
out, and hot or cold fomentations applied. Continu- 
ous irrigation of the sloughing surface with an anti- 
septic solution may be employed. In the form charac- 
terized by cellulitis, disinfection and free drainage of 



166 FEVER NURSING. 

the wound by incision are necessary. The constitu- 
tional treatment of all forms of the infection is sup- 
portive and stimulative. 

Injections of antistreptococcus serum have been em- 
ployed in the disease, with varying results. 

The Diet during the febrile stage should be of 
fluids and easily digested semi-solids. After the tem- 
perature has become normal, easily digestible solids 
may be allowed. 

The nurse should pay the utmost attention to the 
condition of her hands and face. She should carefully 
seal all abrasions of the skin with sterile collodion and 
should thoroughly sterilize her hands after contact with 
the patient. Before attending another patient she 
should bathe and wash her hair with mercury bichlo- 
ride solution, and all clothing worn while in associa- 
tion with the patient should be properly disinfected. 
Aside from these points the general principles of fever 
nursing are applicable in erysipelas. 

* Septicemia. 

Synonym. — Blood-Poisoning. 

Definition. — A disease due to the existence in the 
blood of any of the pus- forming germs and character- 
ized by recurring chills and irregular febrile movement. 

Causation. — Pus germs may effect entrance to the 
body through any abrasion in the skin or mucous mem- 
branes. The site of their entrance may be so minute 
as to be impossible of discovery, or it may be a wound 
of any size or character. The germs having entered 



INFECTIONS WITH LOCAL MANIFESTATIONS. 167 

the system, the symptoms are produced either by the 
germs themselves or the products of their growth 
(toxins), or by both these elements combined. 

Course and Symptoms. — Within a few hours after 
infection has taken place the patient suffers from chilly 
feelings, or a distinct chill, followed by a rise of tem- 
perature. He becomes restless, his skin is hot and dry, 
and there may be headache, general pains, nausea and 
vomiting. The pulse is rapid and the respiration usu- 
ally accelerated. These symptoms may last but a few 
days in mild cases, and then disappear. In severe 
septicaemia the symptoms are greatly intensified and 
those referable to the nervous system are very marked. 
The chill at the onset is severe and at intervals other 
chills occur. The temperature rises rapidly and may 
reach 104 to 106 F. (40 to 41. i° C). In some cases 
the temperature may fall below normal. The prostra- 
tion is great ; the pulse feeble and rapid. As the disease 
progresses the symptoms become those of the typhoid 
state. The tongue becomes brown and dry; the skin 
is wet with cold perspiration. There may be diarrhoea. 
The urine is high-colored and is likely to contain albu- 
min and casts. The wound which is the source of 
infection may become dry, gangrenous and fetid. 

In what is known as the progressive form of septi- 
caemia the symptoms begin less acutely and progress 
less rapidly; otherwise they resemble those just de- 
scribed. The fever may persist for a number of weeks ; 
frequent chills and sweats accompany it and various 
skin eruptions are likely to appear. This variety of 



1 68 FEVER NURSING. 

the disease may prove fatal within a few weeks, or last 
for a long time and eventually end in recovery. 

Prevention. — This consists in careful attention to 
hang-nails and other abrasions when they exist. Such 
abrasions on the person of a nurse attending a septic 
patient should be covered with collodium, or, if neces- 
sary, she should wear rubber gloves. Any wound re- 
ceived while in contact with such a patient must be im- 
mediately cauterized with pure phenol (carbolic acid), 
which should be quickly washed off with alcohol. In 
the absence of this agent, the wound should be sucked, 
to induce free bleeding, and dressed antiseptically. 

Treatment consists in keeping all wounds as clean 
and free from septic material as possible and, in certain 
cases, entire excision of the infected focus. The 
bowels should be kept open by salines ; the fever should 
be combated by cold sponges. Stimulation by means 
of alcohol is frequently necessary. 

The chronic form of the disease, when it is impossi- 
ble to remove the source of the infection, should be 
treated by supportive measures and tonics. 

The Diet should consist of easily digested foods 
in plentiful quantity, and be administered with fre- 
quency and regularity. 

Puerperal Fever. 

Synonyms. — Puerperal Septicaemia ; Puerperal In- 
fection; Child-bed Fever. 

This disease is merely a variety of septicaemia in 
which the point of entrance of the infection is the 



INFECTIONS WITH LOCAL MANIFESTATIONS. 169 

uterine mucous membrane. The chief cause is the in- 
complete removal of placental tissue after childbirth. 
The constitutional symptoms are the same as those de- 
scribed under septicaemia, and, in addition, the dis- 
charge from the vagina may be profuse and very foul. 

With proper care the disease should be almost en- 
tirely preventable. 

During pregnancy the attending physician should 
treat all inflammations of the vulva, urethra, bladder, 
vagina and uterine cervix, in order that at the time of 
delivery there shall be no source from which infection 
may enter the uterus. As the time of labor draws near 
the patient should be told not to touch her genitals. 
The physician should make as few vaginal examina- 
tions as possible, and these only after thorough cleans- 
ing of the parts and sterilization of his hands. The 
nurse should make none at all. In preparing the 
patient for vaginal examination the nurse should first 
cleanse her hands by thorough scrubbing with a brush, 
soap and hot water, afterwards soaking them for five 
minutes in mercury bichloride solution, 1 to 3000 ; she 
should then cleanse the patient's external genitals by 
means of cotton solution wet in 1 to 3000 mercury 
bichloride, and place her in the position preferred by 
the physician. If instruments be used, these must first 
have been boiled. 

During labor the strictest asepsis with regard to 
hands, instruments and dressings must be maintained. 

If the delivery be instrumental, or if manual removal 
of the placenta or its membranes becomes necessary, 



170 FEVER NURSING. 

it is usual to follow these procedures by an intra- 
uterine douche of I to 5000 mercury bichloride solu- 
tion, given from a fountain syringe which has pre- 
viously been washed with hot five per cent, phenol 
(carbolic acid) solution, and through a glass douche 
nozzle which has been boiled. 

During the puerperium all dressings applied must 
be strictly sterile and manipulated with sterilized in- 
struments and hands. Should catheterization become 
necessary it should be performed in the usual manner 
(seep. 52). 

Treatment. — The general treatment of puerperal 
sepsis is identical with that of septicaemia from other 
causes. The special treatment consists in attempting 
to maintain cleanliness in the vagina and uterine cavity. 
This may be done by irrigations of 1 to 10,000 mercury 
bichloride or one per cent, compound solution of 
cresol, which is official, and by packing these cavities 
loosely with ten per cent, iodoform or sterile gauze. 

When the infection is due to retained fragments of 
placenta or membranes, these should be removed by 
blunt curettage, followed by a douche of the compo- 
sition described above. 

Pyaemia. 

Definition. — A febrile disease due to infection by 
pus-forming germs, which are carried by the blood 
from one part of the body to another, and at their 
points of lodgment set up local infectious processes. 

Causation. — The cause of pyaemia has already been 



INFECTIONS WITH LOCAL MANIFESTATIONS, i n 

dealt with in the section devoted to the causation of 
septicaemia (p. 166). The pus-forming germs having 
effected entrance to the blood stream, by this means 
are transferred to various parts of the body, and they 
may cause abscesses wherever they lodge. 

Course and Symptoms. — The symptoms of septi- 
caemia usually precede those of this disease. The onset 
of pyaemia is marked by an intense chill, followed by 
a rapid rise of temperature, general pains, vomiting 
and great prostration. The pulse is rapid and weak. 
Chills frequently recur and the temperature curve is 
marked by frequent quick falls and rises. The tem- 
perature often drops to normal or below, and suddenly 
rises to several degrees above the normal level. There 
are frequent sweats. The patient loses flesh rapidly, 
the tongue is dry, and the breath may have a sweetish 
smell. There may be diarrhoea, with foul-smelling 
stools. Sometimes the skin is slightly jaundiced, and 
various eruptions may appear. The urine is high- 
colored and scanty, and may contain albumin and casts. 
Late in the disease delirium and stupor are frequent. 
The patient grows rapidly weaker and there is a 
marked tendency to the formation of bed-sores. As 
the infectious process is set up in the various organs 
certain symptoms occur as follows : 

(a) If in the lung, pain in the chest, shortness of 
breath, and cough with blood-stained expectoration. 

(b) If in the liver or spleen, pain and tenderness 
referred to the regions of these organs. When abscess 
formation occurs, local swelling is likely to be noted. 



172 FEVER NURSING. 

(c) If in the heart, the pulse becomes more rapid, 
the temperature higher, and the respiration accelerated. 

(d) If in the kidney, there may be pain and there 
usually is bloody and albuminous urine. 

Prevention. — The prevention of this disease is 
identical with that in the case of septicaemia. 

Treatment. — The treatment resolves itself into 
opening and draining the abscesses when their situa- 
tion permits. Otherwise pyaemia should be managed 
in accordance with the methods already laid down for 
septicaemia. 

The nursing of septicaemia, puerperal fever, and 
pyaemia, aside from the special points mentioned under 
these diseases, should be conducted along the same 
lines as those proper in general fever nursing. 

Mumps. 

Synonym. — Epidemic Parotitis. 

Definition. — An acute, infectious disease which is 
characterized by inflammation of one or both parotid 
glands, extending occasionally to the submaxillary 
glands, and rarely affecting by metastasis the testicles, 
ovaries and mammary glands, and which is accom- 
panied by mild constitutional symptoms. 

Causation. — The disease is most commonly seen 
in childhood and youth, and usually occurs in the 
winter and spring. It is more common in males than 
in females. By no means all the children exposed 
contract the disease. Mumps spreads by contact in 
most cases, but it has been known to be communicated 



INFECTIONS WITH LOCAL MANIFESTATIONS. 173 

through a third person and by clothing. Its specific 
cause is not known, and one attack usually confers 
protection. 

Course and Symptoms. — The incubation period is 
usually about two weeks, but may extend to twenty- 
one days. The onset of the disease is marked by chills, 
followed by a rise in temperature to ioi° to 103 F. 
(38.4 to 39.5 C), headache, general pains, and pros- 
tration. In about twenty- four hours one or both par- 
otid glands become swollen and tender, the skin over 
them becomes tense, and there may be pain on swallow- 
ing and sore-throat. An elevation of the lobe of the 
ear is a characteristic sign of parotid swelling. The 
glands may be affected simultaneously or successively ; 
in the latter case the disease is prolonged. The inflam- 
mation reaches its height in from three to six days, 
remains stationary for a day or two, and then declines. 
As the swelling goes down the constitutional symp- 
toms ameliorate. Extension of the inflammation to 
the other salivary glands, or to the testicles, ovaries or 
mammae protracts the course of the infection. 

Complications other than those mentioned above 
and relapses are infrequent. 

Prevention. — The patient and nurse should be 
isolated for at least ten days after the swelling has dis- 
appeared, but the disease is of such mild type that 
the more complicated methods of disinfection are 
unnecessary. 

Treatment. — Rest in bed should be enjoined; very 
little drug treatment is needed; the symptoms should 



i 7 4 FEVER NURSING. 

be controlled as they arise. Hot or cold compresses 
should be applied to the affected glands, the bowels 
should be moved daily, and if the testicles are involved 
they should be allowed to rest upon a shelf constructed 
of a strip of adhesive plaster placed across the thighs 
just below the groins. 

The Diet during the height of the disease should 
be entirely of fluids; the nursing may be carried on 
according to usual methods. 

Bubonic Plague. 

Synonyms. — Malignant Adenitis; The Pest. 

Definition. — An epidemic, contagious, febrile dis- 
ease, characterized by swelling and inflammation of 
the lymph glands and haemorrhages from the mucous 
membranes. It is common in India and Eastern Asia, 
whence it may be imported into Western countries. 

Causation. — It is most common in the hot months 
and is seldom seen in individuals beyond middle life. 

The specific cause of the disease is the bacillus pestis. 
This organism enters the body through the respiratory 
or alimentary tracts or abrasions of the skin, and is 
found in the blood of patients and in the pus from the 
suppurating glands. It is given off in the faeces, urine 
and sputum, and is capable of infecting clothes, bed- 
ding, apartments, and the like. It may be carried by 
fleas and other insects, and by rats, mice, dogs, etc. 

Filthy and unhygienic surroundings predispose to 
the occurrence of epidemics. 



INFECTIONS WITH LOCAL MANIFESTATIONS, 175 

Course and Symptoms. — The incubation period 
lasts from two to seven days, during which time the 
patient may feel indefinitely ill. 

The onset proper is fairly sudden, with chilly feel- 
ings followed by high fever (105 to 106 F. — 40.5 
to 41. 1 ° C), and rapid pulse and respiration. Head- 
ache and general pains are very distressing, and all 
the symptoms of severe infectious disease are met with. 

Vomiting of blood is comparatively frequent. 

The mental symptoms are marked, and delirium may 
appear early. 

Within a few days the glands of the neck, axillae 
and groins become painful, red, tender and swollen. 
The buboes thus formed may be gradually absorbed 
or may rupture, leaving sinuses discharging pus. Rup- 
ture is a favorable sign. Carbuncles and haemorrhages 
into the skin are common in some epidemics. 

The fever lasts about a week, and then, in favorable 
cases, gradually falls ; the other symptoms also amelio- 
rating. The disease, however, is attended by a large 
mortality. 

In certain cases the fever is prolonged for a number 
of weeks as a result of septicaemic implication, and in 
others death from the severe toxaemia occurs within a 
few hours. 

The Pneumonic Type is characterized by respira- 
tory symptoms and bloody sputum which contains the 
bacillus. 

Prevention. — Quarantine and the strictest isolation 
are absolutely necessary, and should be continued for 



176 FEVER NURSING. 

a month after recovery. The measures necessary for 
disinfection of excreta, clothing, apartments, etc., are 
those described in the section on smallpox (p. 205). 

Fortunately, physicians and nurses who exercise 
proper care seldom contract the disease. 

Preventive inoculations by various serums have re- 
sulted in a very considerable diminution in the death- 
rate, and the measure is one not to be neglected. 

Treatment. — The usual symptomatic treatment of 
febrile disease is indicated, and local treatment is also 
required. Cold wet applications should be made to 
the buboes until the presence of pus is evident, and 
then incision and drainage are necessary. 

Further research may prove that intravenous injec- 
tions of anti-plague serums are of benefit. 

The nursing is the same as that applicable to other 
actively contagious diseases. 



CHAPTER VII. 

INFECTIONS OF INTERMITTENT TYPE. 

Malarial Fever: Relapsing Fever: Dengue. 

Malarial Fever. 

Synonyms. — Chills and Fever ; Fever and Ague ; 
Paludism ; Parudal Fever ; Swamp Fever. 

Definition. — An infectious disease characterized by 
paroxysms recurring regularly at various intervals and 
consisting of a chill followed by fever and sweating. 

Varieties. — Tertian (single) , in which the paroxysms 
occur every forty-eight hours. 

Quotidian (double tertian), in which the paroxysms 
occur every twenty- four hours. 

Quartan, in which the paroxysms occur every sev- 
enty-two hours. 

JEstivo-autumnal, in which the paroxysms occur at 
irregular intervals. 

Pernicious, a remittent malarial fever early in which 
the paroxysms may occur regularly, while later in the 
disease the temperature does not fall to normal in the 
interval and may continue high. 

Chronic Malaria (Malarial cachexia) is caused by 
the continuance of any of the above varieties ; there 
may be no febrile movement, but the disease is charac- 
terized by marked constitutional weakness. 

Causation. — Malaria is less common in the very 
young and in aged persons than in young and middle- 
13 i77 



178 FEVER NURSING. 

aged adults ; negroes are less susceptible to the disease 
than whites. Malaria is most common in damp and 
swampy places, and the greatest number of cases is 
observed in late summer and early autumn. 

The specific cause of the disease is a parasite, the 
Plasmodium malaria, which circulates in the blood and 
which in reproducing itself causes the paroxysms. 
There are three types of the organism, each causing a 
different form of malaria. These differ somewhat in 
appearance, but the important difference is that their 
life-cycles are of different durations. The tertian form 
reproduces itself every forty-eight hours, the quartan 
form every seventy-two hours, and the sestivo-autumnal 
form at irregular intervals. The quotidian, or daily 
type, is due to two sets of the tertian organism re- 
producing themselves upon alternate days, so that a 
paroxysm, occurs each day. 

It is believed that these forms are merely different 
types of the same organism acting in different ways. 

It has been conclusively demonstrated that the dis- 
ease may be transmitted from one individual to an- 
other by the bites of certain kinds of mosquitoes, and 
some observers assert that this is the only means of 
transmission. 

Course and Symptoms. — The incubation period is 
variable, but is usually from ten to twelve days. The 
disease caused by the tertian organism is most common 
in the United States, and the estivo-autumnal form is 
the most serious of the three main types. 

A malarial paroxysm consists of a short period 



INFECTIONS OF INTERMITTENT TYPE. 179 

of invasion, during which there may be headache, nau- 
sea and apathy. Then appears the chill, which lasts 
from one-half to two hours ; this usually manifests 
itself late in the morning, and almost never at night. 
In children it may be replaced by a convulsion. Dur- 
ing the chill the patient shivers and complains of great 
cold, which even hot-water bottles and numerous blan- 
kets may not counteract. There is severe frontal head- 
ache and perhaps nausea and vomiting. The pulse is 
rapid and tense. At the end of one or two hours the 
febrile stage commences, and the temperature rises 
very rapidly to 104 or 106 F. (40 to 41. i° C). 
The skin is hot and dry, there is great thirst, and 
there are severe headache and pain in the back and 
limbs. The pulse is full and rapid. There may even 
be brief delirium. The fever lasts from two to twelve 
hours, then falls rapidly to normal, or perhaps to a 
degree or two below, and the stage of sweating begins. 
All the symptoms subside and there is profuse perspi- 
ration. The patient may now go to sleep and wake 
later feeling perfectly well. The next paroxysm occurs 
one, two or three days later, and may begin an hour 
or two earlier or later than its predecessor; in such 
event it is spoken of as anticipated or delayed, as the 
case may be. 

During malarial fever, sores on the nostrils or lips 
are common ; if the paroxysms are repeated for a con- 
siderable time the spleen becomes enlarged and the 
patient grows anaemic. 

In the sestivo-autumnal type the paroxysms last from 



i8o 



FEVER NURSING. 



sixteen to twenty hours and the fever tends to become 
remittent (from ioo° to 104 F— 37.8 to 40 C.) ; 
the beginning chill is milder and gastro-intestinal 
symptoms (vomiting, abdominal distention, diarrhoea) 
are frequently prominent; the headache, restlessness 



OAY OF 
DISEASE 


1 


2 3 


4 5 


6 
































; 


HOUR 


A P 
M M 


A P A f 

NMMII 


A P A F 


A P 
1 MM 


A 


P 
M 


A 

M 


P 
M 


A 

M 


P 

M 


A 

M 


P 


A 
M 


£ 


A. 


P 


A 
M 


M 


A 
M 


M P 


A 

M 


P 

M 


A 
M 


P 

M 


A 
M 


ff 

to 


A 

M 


M 


A 


M 


A 
M 


s 


A 

M 


P 
M 


107 V 
106° 














































































































































































































—43 


























































































































































































































































































































































i«i 










































































































































105 






















































































































































































































































































































































1 104° 

3 103 

J* — m 

a 102 










































































































































'§ 






































































-40 J; 


















































































































































































































































































































































































































— '39 2 














































































































































































































5 
a 101 






: : 














































































































































































































































































§100 










































































































































- „ to 






































































; «£ 






































































-■88 






























































































































































































































































































































































































































98° 
















































































































































































































-37 










































































































































97 






~|f ~: 
























































































































































































































































































































































— 
-36 


96 























































































































































































































































































































































Clinical Chart of Ordinary or Tertian Malaria showing three 
febrile paroxysms occurring on altenate days. 



and sleeplessness are marked; there may be delirium 
followed by stupor or coma; the pulse is rapid and 
frequently weak. This type of the disease may last 
from ten days to a month or merge into 

Pernicious Malarial Fever. — This variety, which is 
rare in the United States, occurs in three important 
forms : 



INFECTIONS OF INTERMITTENT TYPE. 181 

(a) The Comatose Type, in which there are symp- 
toms of severe cerebral disturbance — delirium or coma. 
The onset may or may not be marked by a chill; the 
fever is high (106 to 107 F.— 41. i° to 41.7 C.) 
during the paroxysm; there is profuse sweating; the 
pulse is weak and rapid and there is extreme general 
weakness. This variety is usually fatal. 

(b) The Hemorrhagic Type. — There may or may 
not be a febrile paroxysm; the skin is jaundiced; haem- 
orrhages occur from the various mucous membranes 
or into the skin; the urine is diminished, and is dark 
either from the presence of blood-pigment or blood 
itself (haemoglobinuric or black-water fever). There 
is restlessness or perhaps delirium. The patient may 
die or the paroxysm may subside, though usually only 
to recur. 

(c) The Algid or Congestive Type {Congestive 
Chill). — This is characterized by severe gastric and 
intestinal symptoms (the diarrhoea in particular may be 
very marked), indefinite chilly sensations with clammy 
skin, blueness and great prostration are frequent. The 
temperature usually is not high, and may be sub- 
normal; jaundice is common and the condition is a 
very serious one. 

Malarial Cachexia, or Chronic Malaria, is a conse- 
quence of continued attacks of the ordinary forms of 
the disease and is characterized by extreme weakness, 
yellowness of the skin, and profound anaemia. En- 
largement of the spleen is usual in this, as in other 
forms of protracted malaria. Shortness of breath and 



182 FEVER NURSING. 

swelling of the feet and ankles are common, and bleed- 
ing from various parts of the body may occur. The 
temperature may continue low, or may show irregular 
elevations to from 102 to 103 F. (38.9 to 39.5 C). 

Prevention. — The extermination of mosquitoes and 
the draining of swampy lands go far toward lessening 
the frequency of the occurrence of this disease. 

Treatment. — During the chill the patient should 
be kept warm by means of blankets and hot-water 
bottles. The headache may be relieved by hot or cold 
applications. Sponging with cold water may be prac- 
tised during the febrile stage, and the thirst may be 
mitigated by frequent drinks of cold water or lemon- 
ade. During the stage of sweating the nurse may 
make the patient more comfortable by wiping his skin 
with warm flannel. 

Quinine should be given by mouth in the ordinary 
types of the disease, though not during the height of 
the fever, when it may be vomited; in the pernicious 
types it should be given hypodermatically and in con- 
nection with arsenic. 

Malarial cachexia responds best to quinine, in the 
form of Warburg's tincture, and arsenic, with iron and 
various other tonics to build up the system as adju- 
vants. Massage, especially over the splenic region, is 
useful. 

The diet during the febrile movement should be of 
fluids only, but in the intervals between the paroxysms 
simple solid diet may be allowed. 



INFECTIONS OF INTERMITTENT TYPE. 183 

With regard to points other than those given above 
for the nursing of malaria, the attendant may conduct 
the case in accordance with the general principles of 
fever nursing. 

Relapsing Fever. 

Synonyms. — Famine Fever; Recurrent Typhus; 
Spirillum Fever; Seven Day Fever. 

Definition. — An acute, epidemic infection charac- 
terized by a febrile movement lasting about six or 
seven days, followed by an afebrile interval of about 
a week, after which the febrile paroxysm recurs and 
may be repeated three or four times. 

Causation. — The most favorable conditions for the 
development of the disease are those of famine and 
filth, and epidemics of it have been frequently noted 
in association with those of typhus fever, which is 
favored by the same conditions. The specific cause 
is a spiral-shaped bacterium which circulates in the 
blood, but is not found in the stools and other ex- 
creta. It is found in the blood only during the febrile 
stage. The infection is transmitted by clothing, bed- 
linen, etc., by personal contact, or through a third 
person. Physicians merely visiting cases for short 
periods are less liable to infection than nurses. How 
the organism effects entrance to the body is unknown ; 
possibly it is taken in with the inspired air or through 
the skin. The disease occurs in both sexes and in all 
ages, but is rare in the United States. One attack 
does not protect against subsequent infections. 



1 84 FEVER NURSING. 

Course and Symptoms. — The incubation period is 
usually from four to ten days, although it may be 
much shorter. The onset is sudden, with a chill fol- 
lowed by fever, severe headache, and pains in the back 
and limbs. Sweating is common. The temperature 
rises rapidly, and may reach 104 F. (40 C.) upon 
the first day. The pulse is rapid (no to 130). There 
may be severe nausea and vomiting, as well as marked 
cerebral symptoms. Intestinal derangement is rare; 
jaundice is frequent. The spleen is enlarged and, rarely, 
may rupture. There is no typical eruption, but there 
may be a reddish mottling of the skin or petechial 
spots. The fever, after lasting usually for from five 
to seven days, falls by crisis in a few hours to normal 
or below. Accompanying the fall in temperature there 
is usually sweating and sometimes diarrhoea. The 
patient rapidly regains strength, but in a week (quite 
constantly on the fourteenth day from the initial chill) 
the attack is repeated. The relapse is, as a rule, 
shorter than the first paroxysm, and several (three to 
five) of these may occur, at intervals of seven days. 
Very rarely there is no appreciable relapse, and to- 
wards the end of epidemics the relapse may be slight 
in character. , In protracted cases convalescence is 
slow, for the patient is likely to be much weakened. 
The disease is not a very fatal one, and death, when 
it takes place, is usually due to complications. In 
negroes, however, in whom marked jaundice is al- 
most always a prominent characteristic, it has been 
noted that the mortality is very much larger than in 
whites. 



INFECTIONS OF INTERMITTENT TYPE. 185 

Complications. — Pneumonia and bronchitis are the 
most important ; gastric or intestinal haemorrhages are 
more rare. 

Prevention. — On the appearance of an epidemic 
measures should be taken to provide food for the suf- 
fering poor and to improve the sanitary condition of 



DAY OF 

DISEASE 


L 2 


3 


4 


5 


6 


7 


s 


9 


10 


11 


12 


13 1 


4 15 


ie 


17 


IS 


19 


30 


21 




HOUR * 


P A,P 
M MM 


M M 


a'p 

M U 


m£ 


A'P 

M U 


A.P^ 


A P 


a!f 


mL 


M M 


A^P 
M.M 


a: p a 

M M M 


p a;p 

M M-M 


A P 
MM 


A P 


A.P 
MM 


A P 
M M 


a'p 

M V 


A 

M 


F 






















































































" "12° 


















; 






































































z » 
























































, 




























































































































































nob 
























































































~ti 












































n 




















































































■a ( 












■ j 


1 


— — 












ff iv 












- oK 


a 2 


















































































u AU * 












































— 49 ~ 


■5 E 














































5 inJ- 












































— p 


-'103 - 










































— ^ 


a " f " j 
























































































5 < 


I 








































L 8 * 

— c 


S ino 


| 1 




























































































































3 i 


































































































































































3 


** i 




















































































r3 <-i 








































•9 


a 100 








































—39 3 






























































4 

















— m 

































































































































































































1 ■■ j — 






il 














— lF- 


















- 37 


— £2.- 






— n — 












- V ' 




— t— 












—-7* 




— 36 






















■ 1 












J 






































^ 










































mi "- ' _ 




































































, 






96- 


























1 H 1 















Clinical Chart of Relapsing Fever showing the febrile movement 
upon the fourteenth day. 



their surroundings in every way, especially by attention 
to the proper disposal of garbage. Although there is 
no proof that the disease is transmitted by drinking 
water, it is wise to boil all water used for this purpose. 
Relapsing fever does not spread readily under condi- 
tions of cleanliness and where ventilation is thorough ; 



1 86 FEVER NURSING. 

consequently, plenty of fresh air should be given access 
to the sick-room and when the disease has run its course 
the apartment, as well as the clothing, bedding and 
utensils, must undergo proper disinfection. 

Treatment. — The patient should be isolated and 
kept under strict quarantine. There is no drug which 
affects the course of the disease ; so that the symptoms 
must be treated as they arise, according to general prin- 
ciples. The temperature may be controlled to some 
extent and the patient be made more comfortable by 
cold sponging. The diet should be fluid, but in the 
afebrile intervals semi-solids may be allowed. When 
there is extreme prostration very free stimulation is 
necessary. 

The nursing should be conducted according to the 
methods usual in febrile diseases. 

Dengue. 

Synonyms. — Breakbone Fever; Dandy Fever. 

Definition. — Dengue is an acute, infectious febrile 
disease occurring in warm countries and characterized 
by pains in the muscles and joints and an erythematous 
skin eruption. 

Causation. — It occurs chiefly in hot climates and 
at the warmer and more moist seasons of the year. It 
is common in the East and West Indies, but is seldom 
seen in the United States, except along the coast of the 
Gulf of Mexico. It is believed to be caused by a 
microorganism which circulates in the blood and is 
transmitted through the bites of mosquitoes, in the 



INFECTIONS OF INTERMITTENT TYPE. 187 

same manner as the infection of yellow fever. The 
infection is probably not transmitted by contact with 
patients nor through clothing, etc. The disease is 
seldom fatal. 

Course and Symptoms. — The incubation period is 
from two to five days. The onset is marked by an 
acute chill, or in the case of children by a convulsion. 
A rise of temperature to from 104 to 106 F. (40 to 
41. 1 ° C.) follows. The pulse is rapid and there are 
nausea, vomiting and severe headache, accompanied 
by pain and tenderness in the muscles of the trunk and 
limbs. The joints are hot, painful, red, tender and 
sometimes swollen. The pains in the joints and mus- 
cles, causing a stiff gait, have given rise to the name 
" dandy fever." The glands of the neck, axillae and 
groin may be swollen. There are flushing of the face, 
suffusion of the eyes, a coated tongue, highly colored 
and scanty urine, and weakness and prostration. The 
eruption is a reddish blush, which may itch and which 
usually disappears on the third or fourth day; it is 
sometimes followed by desquamation. 

The rise in temperature lasts from three to five days 
and then falls by crisis accompanied by sweating and 
amelioration of all the symptoms. The temperature 
remains normal for several days and then the symp- 
toms of the onset of the disease return, but with less 
severity ; during this recurrence various forms of erup- 
tion may appear on the skin. The recurrence lasts 
from two to three days, when a second crisis ensues ; 
after which convalescence is established. 



1 88 FEVER NURSING. 

The patient recovers strength slowly and is likely to 
be troubled by a persistence of the joint pains. 

Relapses are not infrequent, but complications are 
rare. 

Prevention of the disease consists in destroying 
the mosquitoes, preventing their access to patients ill 
with the infection, and protecting the healthy from 
their bites. Quarantine and disinfection, in the light 
of our recently acquired knowledge of the mode of 
transmission of the contagium, are unnecessary. 

Treatment. — The patient should be kept in bed 
while the symptoms are acute. The medicinal treat- 
ment is wholly symptomatic ; the pains may be relieved 
by the administration of various analgesic drugs and 
the joint inflammation lessened by applications of cold 
or heat. 

The Diet during the febrile stages must be of fluids 
alone ; during convalescence strength-giving foods 
should be given in easily digestible forms. 

The nursing should be carried on in accordance with 
general principles. 



CHAPTER VIII. 

THE EXANTHEMATA. 

Scarlet Fever: Smallpox: Chickenpox: Measles: German 
Measles: The Fourth Disease of Dukes: Epidemic Cere- 
brospinal Meningitis. 

These diseases are known as the infectious exan- 
themata (from a Greek word meaning an eruption), 
and are characterized each by a typical rash upon the 
skin. They are all contagious and, except smallpox, 
are most frequently seen in children. 

Scarlet Fever. 

Synonym. — Scarlatina. 

Definition. — An acute, infectious fever character- 
ized by a scarlet rash upon the skin and usually accom- 
panied by sore-throat. 

Causation. — The disease is endemic and at times 
appears in epidemics of varying intensity. The ma- 
jority of cases occur in children under ten years of 
age. Nursing infants, however, seldom contract the 
disease; during pregnancy and after surgical opera- 
tions susceptibility is increased. Certain individuals, 
some families and certain races, for instance the Japa- 
nese, seem unable to acquire the infection. Scarlet 
fever is due to a specific organism which it is believed 
has been recently discovered. 

189 



19° FEVER NURSING. 

The infection is spread chiefly by the flakes of skin 
cast off by the patient and perhaps also by means of 
his exhalations. The contagium clings persistently 
to clothing, books, toys, and the like, and is capable of 
transmitting the disease for months and even years. 
The physician or nurse may carry the infection to a 
third person. Epidemics are most frequent in the au- 
tumn and winter. One attack usually protects against 
subsequent infections. It should be remembered that 
scarlatina is not a light form of scarlet fever, but that 
the two terms have exactly the same meaning. 

The eruption appears from twelve to thirty-six hours 
after the onset of the disease, in the form of tiny red 
points; these may be so numerous and close together 
as to give the appearance of diffuse redness ; they may 
occur in irregular patches or they may be widely 
scattered. 

The rash appears first on the neck and shoulders 
and extends to the trunk, arms and legs. In from one 
to four days it reaches its maximum and the skin 
becomes almost uniformly red and swollen. Drawing 
the finger-nail over the skin leaves a whitish line which 
quickly disappears. The eruption is most marked upon 
the parts of the body which are kept warm. Upon the 
face the eruption is much less marked and usually 
appears only on the forehead and cheeks, the skin 
about the nose and mouth remaining pale. The erup- 
tion remains at its height for from one to three days 
and gradually disappears as the temperature approaches 
normal. 



THE EXANTHEMATA. 19 J 

Irregular eruptions are frequent and puzzling ; they 
may appear only upon the trunk, the limbs or the face ; 
they may remain in the stage of diffuse patches ; they 
may last but a few hours ; they may be entirely absent. 

Course and Symptoms. — The incubation period is 
usually one week, but may vary from one day to three 
weeks. Usually during this time there are no symp- 
toms except possibly slight sore-throat. The invasion 
is sudden, with a chill or convulsion followed by a rise 
of temperature (104 to 106 F. — 40 to 41. i° C), 
rapid pulse, headache, vomiting and sore-throat. In 
from twelve to thirty-six hours the eruption appears, 
and in about four days the entire skin is red, inflamed 
and tense ; the rash may be present upon the mucous 
membranes of the mouth and throat, causing them to 
appear vividly red. The tongue is at first coated in 
the centre and red and clean at its edges and tip. 
Through the coating the red tips of the papillae may 
be seen, giving the so-called " strawberry " appear- 
ance. In a few days the coating peels off, leaving the 
tongue red and roughened — the " raspberry " tongue. 
The fever continues, with slight morning remissions, 
and falls gradually as the rash fades ; reaching normal 
about the seventh day. 

The sore-throat varies in intensity from a slight red- 
ness and swelling of the fauces and tonsils to a marked 
inflammation with a false membrane involving all the 
parts about the pharynx and accompanied by enlarge- 
ment of the glands under the jaw. 

The spleen may be slightly enlarged. The urine 



192 



FEVER NURSING. 



presents the characteristics usual in febrile disease and 
the existence of albuminuria is frequent. Daily ex- 
aminations of the urine should be made, and it is part 
of the nurse's duty to save specimens for them. 

As the temperature falls the symptoms ameliorate. 

Desquamation. — As the fever and rash disappear the 



»St£A8E 


1 


2 


3 


4 5 


6 


7 


8 


9 


10 


11 


12 






















HOUR 


M 


P t 

M 1 


p 

i M 


A 

M 


p 

M 


l7f 

M 


PA 
M M 


■P A 
M M 


p 


A 
M 


P 
M 


A 
M 


P 
M 


A 
M 


P 

M 


A 

M 


P 
M 


\ P 
MM 


A 
M 


P 
M 


A 

M 


P 


A 
M 


P 
M 


A 
M 


P 
M 


A 
M 


P 
M 


A 

M 


P 

M 


A 
M 


p 

M 


A 


P 

M) 


A 
M 


P 
M 


A 
M f, 


i 


























































































































































~ 4Q 


107 












































































"l<rf 






























































































































































































































































































































































































~105 C 
























































































































































irr^l 






































































































































































































































V 

a 104 












































































"I h' 






K 












































































n 




A 


































































w 










\ 






















































— 




















- 




































































8 

£108 








y 




































































: — 40 a 






1 






tj 


1 










































































J 


1 


































































«, 










\ 












































































































































|l02° 












































































zz h 


























































































V 


























































































































































5» 




























































:— 39 w 


p3 101 
















3 












































































j 








































































































































i~ b 












































































-- <f 
















t 






























































§100 
















V 


r^ 












































































\ 


























































-- a 


















1 


























































-- era 












































































-38 a 


Ml 












































































"z 8* 




































































































































































































































_ - 


























































































































































-^ 


98 u 














































































97 


















































































































































































































































































































96 




































































































































































































































Z~ v 5 




























































































— 1 — 































































Clinical Chart of Scarlet Fever. 



skin becomes dry and roughened and its upper layer 
loosens. This takes place first upon the chest, and 
gradually the dried flakes fall; the process continues 
from two to three weeks. Rarely the hair and nails 
are lost. 

Severe Forms of the Disease — The Anginose 
Form. — This is characterized by extreme severity of 



THE EXANTHEMATA. 193 

the throat inflammation. The pharynx and tonsils are 
swollen and red, and a membrane forms which may 
extend upward to the posterior nares or forward into 
the mouth; the lymph glands beneath the jaw and in 
the neck are swollen and necrosis of the tissues of the 
throat may follow ; with this there is a very foul odor. 
The inflammation may go on to involve the middle ear 
and more rarely the trachea and bronchi. Any symp- 
toms referable to the ear should be at once reported to 
the physician. The prostration is very marked. If 
the disease is not rapidly fatal, abscesses frequently 
form in the tissues of the neck. Recovery is rare. 

The Hemorrhagic Form. — In this variety haemor- 
rhages may take place into the skin or mucous mem- 
branes, and may be evidenced by hsemorrhagic spots 
upon the skin, nose-bleed, or bloody urine. In this 
type death may occur as early as the third day. 

The Malignant Form. — In this the invasion is very 
severe and accompanied by marked cerebral symptoms 
— delirium or stupor; there may be suppression of 
urine, the temperature rises rapidly to a very high point 
(io8° F. — 42.2 C), and death is likely to supervene 
even before the rash is developed. 

Complications and Sequelae. — The most important 
of these are nephritis and inflammation of the middle 
ear. The nephritis varies in intensity from a mild 
type, with slight albuminuria and hardly noticeable 
oedema of the feet and ankles, to severe inflammation 
with diminished or even suppressed urine. In the 
intense cases there are considerable albumin, numerous 

14 



194 FEVER NURSING. 

casts, and perhaps blood in the urine, marked dropsy, 
constant vomiting, and uraemic convulsions. Some of 
these patients die, or the disease may go on to perma- 
nent chronic nephritis; but prompt and proper treat- 
ment may result in the disappearance of the symptoms 
and the return of the kidneys to a healthy condition. 

Ear Complications are frequent and are due to an 
extension of the throat inflammation through the Eusta- 
chian tubes. The otitis causes severe pain, which per- 
sists until the drum membrane ruptures or is punctured, 
allowing the escape of the pus. The ear inflammation 
may extend to the mastoid processes or even to within 
the skull, and cause various meningeal and brain com- 
plications. Deafness is not an uncommon result. 

Joint Complications, with all the symptoms of acute 
articular rheumatism, may occur. These usually ap- 
pear after the temperature has fallen to normal, but 
may show themselves during the febrile movement. 

Heart Complications are not rare, and often result 
in a permanent affection of one or more of the valves 
of that organ. Inflammations of the pericardium and 
of the heart-muscle may occur as well. 

Pleurisy and Pneumonia are infrequently associated 
with scarlatina. 

Chorea sometimes complicates the disease and is 
most likely to occur when the scarlatina is followed by 
endocarditis and arthritis. 

Throat Complications. — These have been considered 
above (see page 192). 



THE EXANTHEMATA. 195 

Prevention. — The patient should be immediately 
isolated and other children of the family removed. 
These latter should be kept from association with other 
children for ten days at least in order that the disease 
may develop if they have been exposed ; careful watch 
should be kept of their throats. 

The hygiene of the sick-room should be the same as 
in other contagious diseases {see pp. 149 et seq.), and 
all clothing, dressings, utensils and discharges should 
be cared for in exactly the same manner. Free venti- 
lation of the sick-room is important and a temperature 
of 65 to yo° F. (18 to 20 C.) should be maintained. 
The patient must be kept in bed, even when the disease 
seems the mildest, and lightly covered, but should be 
sedulously guarded from draughts. Both the physi- 
cian and the nurse should wear a cap and gown over 
their ordinary clothing when in the patient's presence, 
and the former upon leaving the sick-room should pass 
directly into the open air. A sheet wet with five per 
cent, phenol (carbolic acid) solution and suspended 
before the door of the apartment is an excellent 
measure. 

The quarantine should be continued for from six to 
eight weeks (longer if desquamation has not ceased 
during this period), and when it is raised both patient 
and nurse should bathe as after smallpox {see page 
205), and the apartment with its contents should be 
disinfected after the usual manner and thoroughly 
aired. Books, toys, and the like, with which the patient 
has come in contact should be burned. 



i9 6 FEVER NURSING. 

Treatment. — The general treatment of the disease 
is symptomatic. Considerable research has of late 
been carried out along the line of serum treatment, 
but so far the results have been inconclusive. 

The patient should receive two lukewarm sponge 
baths daily, and if there is distressing itching and 
burning of the skin he may be lightly smeared with 
albolene, olive oil, or cacao butter. This should be 
done twice a day when desquamation has commenced, 
for it is not only grateful to the patient, but also pre- 
vents the dissemination of the flakes of skin. 

Copious and frequent draughts of water, plain or 
carbonated, should be urged upon the patient, and in 
cases with very high temperature two cool baths (90 
to 70 F. — 32.2 ° to 21.1 C.) should be given daily. 
The mouth, throat and nose should be subjected to fre- 
quent spraying and cleansing with Dobell's or other 
alkaline solution, for by this means aural involvement 
may be in a great measure prevented. The urine must 
be examined daily, and the nurse should prepare a 
specimen each day before the physician's visit. 

The Diet. — During the febrile stage the diet should 
be of fluids alone (see general principles of feeding in 
fevers, p. 58), but when the temperature has become 
normal a gradual return to solid diet is advisable. In 
cases with albuminuria, meats must not be allowed as 
long as this symptom persists. 

The nursing should be carried on in accordance with 
the principles laid down for the infectious diseases. 



THE EXANTHEMA TA. 1 9 7 

Smallpox. 

Synonym. — Variola. 

Definition. — Smallpox, as distinguished from grand 
pox (syphilis), is an acute infectious disease charac- 
terized by a typical eruption appearing first in the form 
of macules or spots, and becoming successively papules, 
vesicles and pustules, upon the last of which crusts 
form which drop off and leave scars. 

Causation. — The disease has existed as an epidemic 
since many centuries before Christ, and until the intro- 
duction of vaccination was so universal a scourge that 
persons who showed no pock-marks were rarely seen. 
Its specific cause is believed to be a recently discovered 
microorganism. Smallpox is contagious throughout 
its entire course after the eruption has appeared, and 
a few moments of association with an individual suf- 
fering from it are a sufficiently long time to contract 
the disease. The contagion may be carried great dis- 
tances in clothing, etc., and the pulverized dry crusts 
retain the power of transmitting the infection for sev- 
eral years. Inoculation from the contents of the vesi- 
cles and pustules, the scabs, and the blood is possible. 
It is believed that the infection enters the body with 
the inspired air, and it probably exists in the secretions 
and excretions and in the exhalations from lungs and 
skin. The severest type of smallpox may be con- 
tracted from a person who apparently suffers from a 
very mild attack. The disease respects neither race, 
age nor sex, and very few unvaccinated persons escape 
after exposure. Usually, but not always, one attack 



i9 8 FEVER NURSING. 

precludes the possibility of a second infection. Inas- 
much as this disease occurs almost exclusively in 
unvaccinated persons, it may be said to be a disease 
of choice. 

The Eruption appears about the third day, first upon 
the face and scalp, and then spreads until it involves 
most of the skin and mucous membranes. At first it 
is in the form of round, red spots, which by the second 
day become slightly elevated; by the sixth day these 
have become vesicles with depressed centres (umbili- 
cated), and by the eighth day they have changed into 
pustules. As this last transition is taking place the 
skin and mucous membranes become swollen and in- 
flamed. If the pustules extend into the deeper layers 
of the skin, scars (pock-marks) result. 

The eruption appears upon the tongue and the lining 
of the mouth and throat; rarely it extends into the 
oesophagus and stomach; it may show itself in the 
rectum. In the larynx it is accompanied by inflamma- 
tion and sometimes by oedema. Rarely the eruption 
appears first upon the mucous membranes. The above 
is a description of the discrete form of the eruption; 
in the rarer types of the disease the rash may undergo 
various modifications. 

Course and Symptoms. — The incubation period is 
usually from ten to fifteen days. The invasion is 
sudden, with a distinct chill or chilly sensations fol- 
lowed by a rapid rise of temperature (103 to 106 
F. — 39.5 ° to 41. 1 ° C). The pulse is rapid (100 to 
120) and full, the respirations are accelerated, the 



THE EXANTHEMATA. 



199 



tongue is coated, and there may be vomiting, convul- 
sions or delirium. There are severe headache and 
general pains. A pronounced aching pain in the small 
of the back is so typical as to be an aid in distinguish- 
ing smallpox from other eruptive fevers. A feeling 
as of shot under the skin of the palm at the base of 




Clinical Chart of Smallpox showing fall of temperature upon the 

appearance of the eruption and its rise upon the incidence of 

the stage of pustulation. 



the thumb, due to the undeveloped eruption, is another 
early diagnostic point. There may be sore-throat and 
conjunctivitis; there is usually enlargement of the 
spleen ; bleeding from the skin and mucous membranes 
are rarer symptoms. 



200 FEVER NURSING. 

On the second or third day certain rashes (not the 
true smallpox eruption) may appear in the form of 
petechiae, streaks or diffuse blushes, which are reddish, 
brownish or purple in color. These become paler on 
pressure. They are not raised and may occur on any 
part of the body, but are most frequently seen on the 
inner sides of the thighs and arms, the groins, upper 
abdomen, and chest. About the third day the typical 
eruption appears, and in a favorable case the tempera- 
ture falls and the other symptoms subside. The erup- 
tion then passes through its various stages, until finally 
scabs form which drop off and leave scars behind. 
The healing of the eruption may be accompanied by 
troublesome itching. 

The Confluent Form of smallpox follows a shorter 
period of incubation and is ushered in by severe symp- 
toms; the temperature may rise as high as no° F. 
(43.3 C), and as the eruption appears there is very 
little amelioration of the patient's condition. The 
papules are large, and when they become pustules they 
run together, so that the skin is infiltrated with pus. 
The confluency may be confined to the face, hands and 
feet, or it may involve the entire surface of the body. 
The mucous membranes are swollen and much in- 
flamed, and may become gangrenous. With this inflam- 
mation all the symptoms of sepsis are present — rapid, 
feeble pulse, marked nervous symptoms, and great 
prostration. An intolerable odor rises from the pa- 
tient, and the picture presented by him is perhaps more 
horrible than that in any other disease. The forma- 



THE EXANTHEMATA. 201 

tion of scabs in this variety of smallpox may take three 
or four weeks. 

The Malignant Form. — In this type of the disease 
the temperature may never be high, but the consti- 
tutional symptoms (especially those referable to the 
nervous system) and the prostration are very marked. 
This form of smallpox is usually fatal. In it the rash 
is likely to be typical, but death may take place before 
the rash appears at all. 

The Hemorrhagic Form is characterized by the 
effusion of blood into the skin and the pustules, and 
bleeding from the mouth, nose, lungs, stomach, or any 
of the mucous membranes. This type as a rule is 
fatal, death occurring sometimes as early as the third 
or fourth day. Neither this nor the malignant variety 
is often seen in persons who have been vaccinated. 

Varioloid is true smallpox occurring in individuals 
who have been vaccinated, and is a shorter and milder 
disease than the unmodified variety. The eruption is 
not extensive, the pocks are small, and some of the 
vesicles may dry without becoming pustules; there is 
rarely any scarring. The initial symptoms are not se- 
vere, with the exception of the pain in the back, and 
when the rash appears, which it usually does about the 
third or fourth day, the constitutional disturbance sub- 
sides. The eruption dries and the scabs fall from five 
to seven days after the appearance of the eruption. 

The severe types of smallpox may be contracted by 
unvaccinated persons from the mild form. 

Prevention. — The introduction of vaccination by 



2Q2 FEVER NURSING. 

Jenner at the close of the eighteenth century has caused 
smallpox to become a rare disease in communities 
where the measure is systematically practised, and too 
great insistence cannot be laid upon the necessity for 
the routine performance of the procedure. All chil- 
dren should be vaccinated at from three to five months 
of age, every seven years thereafter, and in the in- 
tervals whenever the disease is prevalent ; at such times 
one should never be satisfied with an unsuccessful 
attempt. Vaccination does not always protect, but 
the disease as it occurs in those who have undergone 
the operation is very rarely severe. 

Vaccination is performed as follows: The site 
selected is, in the case of boys, the outer side of the 
arm at the junction of its upper and middle thirds. In 
vaccinating girls in the upper walks of life it is pref- 
erable to use the outer side of the calf. Human 
lymph or calf lymph may be used, but the latter is 
preferable. The skin over the part chosen should be 
sterilized by washing with soap and water, followed 
by alcohol and I to 5000 mercury bichloride solution, 
after which it is wiped off with sterile water and 
allowed to dry. Then with a needle which has been 
sterilized by heating in a gas flame a surface one- 
eighth to one- fourth of an inch in diameter is lightly 
scratched, care being taken not to draw blood, but 
merely to remove the upper layers of the integument. 
A slight exudation of serum will follow this procedure, 
and into this the vaccine should be rubbed for several 
minutes. The surface should be allowed to dry, and 



THE EXANTHEMATA. 203 

then be dressed lightly with a compress of sterile gauze. 
The various shields sold to cover vaccination wounds 
should not be used. Different makers supply dried 
vaccine upon quills or ivory points. When from a 
reputable manufacturer these may be used. The 
health boards of certain cities furnish calf lymph put 
up in glass tubes and packed with a needle, a bit of 
wood, and full directions for the performance of the 
operation. When available such an outfit may be 
employed. 

The train of symptoms following vaccination is 
termed vaccinia and it differs in different individuals. If 
the procedure is successful and the vaccination " takes," 
a papule appears about the third day; on the fifth to 
the seventh day this becomes a vesicle surrounded by a 
red area, which about the eighth day becomes the seat 
of a suppurative process and is painful and tender. 
From this time the inflammation gradually subsides, 
and about the twenty-first day the scab falls, leaving 
the familiar whitish scar. Protection is believed to 
be effected about the thirteenth day. 

About the third day after vaccination there may be 
a rise of temperature, which may last a week or more ; 
with this there are headache, gastric disturbances, rest- 
lessness, etc., but usually these symptoms are of little 
moment and require no special treatment. Frequently 
there is enlargement and tenderness of the axillary or 
inguinal glands, depending upon the site of the inocu- 
lation. 

Generalized Vaccinia is rare, but may manifest itself 



204 FEVER NURSING. 

as a pustular rash on different parts of the body, ap- 
pearing on the eighth to the tenth day ; the pustules are 
most abundant upon the vaccinated limb and may con- 
tinue to appear for several weeks. The disease may 
prove fatal in children. 

Complications of Vaccination. — Syphilis may follow 
if infected humanized lymph be used, and tetanus has 
been known to result from the employment of con- 
taminated bovine virus. Erysipelas and septicaemia are 
possible complications, but proper antiseptic precau- 
tions will prevent their occurrence. 

When a case of smallpox appears in the community, 
every person who has recently associated with the in- 
dividual should immediately be vaccinated, no matter 
how short a time previously this has been done. It is 
also wise to vaccinate the patient, though this seldom 
results in any modification of the disease. 

General Management. — The patient should be sub- 
jected to the strictest isolation, no one being allowed 
to approach him but his nurse and physician. It is 
best to procure a nurse who has had the disease, 
and if this is impossible, one who has recently been 
vaccinated successfully. The nurse and physician 
should wear caps of oiled silk or rubber, and linen or 
cotton gowns enveloping the whole figure, when in 
the sick-room. They should wear rubber gloves, and 
the physician rubber shoes, and these should be kept 
in the room and disinfected before being used again. 
Their visits to the patient should be as brief as pos- 
sible. The room in which the patient is confined 



THE EXANTHEMATA. 205 

should be emptied of all draperies and superfluous 
furniture, and should be thoroughly ventilated at all 
times. An apartment with a fire-place is best, for 
in addition to improving ventilation, this offers a place 
for burning all contaminated substances. All the 
patient's excreta should be disinfected in the manner 
described on page 79, and it is wise to suspend before 
the door a sheet wet with five per cent, phenol (car- 
bolic acid) solution; just outside which disinfectants 
should be kept in which physician and nurse may 
wash their hands and faces after leaving the patient. 
All washable clothing both of nurse and patient should 
be soaked in a disinfecting solution for from six to 
ten hours before it is taken to the laundry, and then 
it should be thoroughly boiled. After the patient's 
recovery or death everything with which he has come 
in contact should be burned. If there is a disinfecting 
plant available, the mattresses and bedding may be 
disinfected by steam under pressure, but either this 
process or burning is absolutely necessary. When 
the quarantine is raised, which must not be done until 
the last scab has fallen, the patient and nurse should 
bathe in a 1 to 2000 mercury bichloride solution, care- 
fully protecting the eyes; the hair should be sham- 
pooed, and clean clothing put on in another room. 

If the patient dies, the body should be wrapped in 
a sheet wet with 1 to 2000 mercury bichloride solu- 
tion, sealed in a metal coffin, and cremated or buried 
as soon as possible. 

The apartment should be disinfected according to 
the usual methods and thoroughly aired. 



206 FEVER NURSING. 

Treatment. — The treatment of the disease is symp- 
tomatic. The patient's hair should be cut short, and 
the tendency to pitting may be lessened if strict atten- 
tion is paid to cleanliness, and if the patient wears, 
to keep him from scratching, gloves and a gauze mask 
moistened with either a two per cent, phenol solution or 
a saturated one of boric acid. Frequent immersions in 
warm water or cleansing with hydrogen dioxide solu- 
tion will aid in keeping the skin clean and free from 
pus. A thin ointment of ichthyol of ten per cent, 
strength is very soothing to the face. 

The feeding and the nursing, on points other than 
those discussed above, should be conducted according 
to general principles. 

Chicken-Pox. 

Synonym. — Varicella. 

Definition. — An acute, infectious, febrile disease of 
mild type characterized by a vesicular eruption. 

Causation. — The disease is sporadic and occurs also 
at times in epidemics. It is essentially a disease of 
children and but very rarely is seen in the adult. It 
occurs in all climates and at all seasons. Its specific 
cause has not yet been discovered, but is probably a 
bacterium. It probably effects entrance to the body 
with the inspired air, and the contagium is given off 
from the patient. One attack usually, but not invari- 
ably, confers immunity. 

The Eruption as a rule appears on the first day of 
the disease, first upon the face and scalp and later upon 



THE EXANTHEMATA. 207 

the neck, body and limbs. The rash begins as a 
rounded red spot, which quickly becomes a papule and 
reaches the vesicular stage within a few hours. The 
vesicles vary in size from one-sixteenth to one-half an 
inch in diameter. Occasionally a few vesicles go on 
to the pustular form. There is no umbilication, and 
when pricked the vesicle collapses entirely, which is 
not the case in smallpox. The eruption lasts from two 
to five days, when the vesicles dry, form crusts, and 
soon fall; ordinarily leaving no scar. If the vesicles 
are scratched, however, they may leave cicatrices. 
The pustules may leave a slight depression which is 
almost never permanent. Successive crops appear, 
and we may see the eruption in all stages at the same 
time. The eruption may appear in the mouth and 
throat. 

Course and Symptoms. — The incubation period is 
from ten to fifteen days; the period of invasion lasts 
one or two days, with slight fever and malaise. The 
onset is marked by chilly feelings (seldom by con- 
vulsions), moderate fever (ioo° to 102 F. — 37.8 to 
38.9 C), general pains, nausea and prostration. The 
eruption appears within twenty-four hours, and the 
fever and other symptoms rarely last more than two or 
three days. 

Complications are infrequent. 

Prevention. — The patient should be isolated until 
the last crust has fallen; then the sick-room may be 
disinfected, though cleaning and airing are usually 
sufficient. 



208 FEVER NURSING. 

Treatment is usually unnecessary except in so far 
as cleanliness is concerned. The large vesicles may be 
opened and washed with boric acid solution ; the itch- 
ing may be relieved by the application of olive oil, 
which will also be found useful in loosening the crusts. 
It may be necessary to place mittens upon the patient's 
hands to prevent scratching. In any case the finger 
nails should be kept short and frequently cleansed with 
soap, water and a brush. 

During the febrile stage fluid diet is to be preferred, 
but as soon as the temperature reaches normal, easily 
digested solids may be given. 

Nursing should be conducted in accordance with 
general principles. 

Measles. 

Synonyms. — Rubeola ; Morbilli. 

Definition. — Measles is an acute, infectious fever 
characterized by congestion of the upper air passages 
and conjunctivae and accompanied by an eruption of 
maculo-papular form. 

Causation. — The disease is commonly endemic, epi- 
demics appearing at intervals. It usually appears in 
children, but adults often contract it ; it is most preva- 
lent in the cold months. Its specific cause is a germ 
which has not yet been discovered. The infection is 
spread by contact, by the breath, by the secretions 
(especially those of the nose), by articles which have 
come in contact with sufferers from the disease, and 
through a third person. One attack usually, but by no 



THE EXANTHEMATA. 209 

means always, confers immunity; several attacks in 
the same individual have been observed. 

The Eruption appears about the fourth day; it is 
maculo-papular in form, and the spots, at first round- 
ish, rose-colored, slightly elevated papules, tend to 
coalesce into a crescentic shape. The rash appears 
first on the face and mucous membrane, then upon the 
body, and last upon the extremities; it is fully de- 
veloped in from two to four days, and then gradually 
fades. In from ten to fourteen days fine desquamation 
takes place. Rarely the rash may be vesicular or 
hemorrhagic. 

A day or two before the eruption small red spots, 
from the size of a pin-head to that of a split pea, 
appear on the lining of the cheeks and mouth. At 
the centre of each is a bluish-white spot which may 
be made out with the aid of a strong light. These 
are known as Koplik's spots, and are a certain and 
early diagnostic sign of the disease. 

Course and Symptoms. — The incubation period is 
from ten to fourteen days; the period of invasion 
usually lasts four days. The disease is ushered in by 
chills or convulsions, followed by a rise in temperature 
to from 105 to 106 F. (40.5 to 41. i° C), head- 
ache, prostration, rapid pulse, vomiting and commonly 
diarrhoea. There are usually conjunctivitis and rhi- 
nitis ; the tongue is coated, and the glands of the neck 
may be swollen. During the height of the fever, stupor 
or delirium may be present. In from ten to fourteen 
days the eruption disappears, the fever subsides, and 
convalescence is established. 



2IO 



FEVER NURSING. 



The Hemorrhagic Type (Black Measles) may occur 
during epidemics in institutions where many children 
are congregated or among savage races attacked for 
the first time. The eruption is dark, and bleeding 
takes place into the skin and from the mucous mem- 
branes; the nervous symptoms are marked, the tern- 



DAY OF i 

3ISEASE " 


L 2 


3 4 


5 6 


7 8 


9 10 11 


12 13 1 


i 15 














HOUR £ 


PAP/ 


iPAF 
IMMt 


A P A F 


> A P A P > 


P A F A i 


A P A 
A M M M 


P A 
M M 


P A 
M M 


P 

M 


\ P 

^ M 


•A P / 

MM! 


VP A 
it M M 


P 
M 


A P 

M M 


A P 
M M 
























































































































































































































































































:zs_. : 
























-41° 










SL 53 
































: ?s : 
































- %■% - 
























105 








































Z _»d. a- — - 
























/-S C 








:-| — : 
























H 


































-40 3 

ft 


•s 1U4 








: £c : 
























■9 








:- cs: 3: 
























£ c 








^3 - 
























2 1ft-} 






Z I 


-4 r 
























J3 - ■ - ■ 






- ».-V- 


































- **■- 


- - 

z 


*3 " 






















>■ 












._! : 
























.» c 


t- 






























39 pd 


^102- 


__ 3 . 






























§ — 


— — - 


~firJ 




























W 




d 


rS 




























z o 

_ a 

SJ 




~f 


3 - 






























i 


: 






























I 
































tz 






























































gioo- 
































— 38 <3 


§ 
































- a> 


































H 99° 












- r*- 
































=i s 


+ + 




*-- 


























































































































































































































































































































































































36 





































































































Clinical Chart of Measles showing defervescence by lysis beginning 
when the eruption is fully developed. 



perature high, and the prostration extreme. Gangrene 
of the face sometimes occurs as a complication. This 
form of the disease is very fatal. 

Complications. — Convalescence may be interrupted 
by a continuance of the conjunctivitis, or by pharyn- 
gitis, inflammations of the ear or the lymph glands, 



THE EXANTHEMA TA. 211 

bronchitis, or, most important of all, broncho-pneumo- 
nia. Whooping-cough or diphtheria may be associated 
with the disease. The inflamed glands offer a fertile 
field for infection by the tubercle bacillus, and such an 
infection may be followed by acute miliary tuberculosis. 

Prevention. — The measures to be taken to prevent 
the spread of the disease are the same as those appli- 
cable in scarlatina, but are less likely to be successful, 
for the contagium, although its life is shorter, seems to 
be much more easily diffusible. The patient should be 
isolated in an airy room, protected from draughts, and 
not allowed to associate with others until at least two 
weeks have elapsed since the onset. Many parents 
encourage their children to expose themselves, on the 
principle that every one must contract the disease, but 
this is little less than criminal. 

All discharges, dressings, clothing, etc., should be 
disinfected according to the usual methods. 

Treatment. — The patient should be kept in bed in 
a dark room while the temperature is elevated, and 
should be given at least one sponge bath with cool 
water daily. A disinfecting bath for both patient and 
nurse at the termination of the period of isolation is 
an essential. The eyes should receive careful atten- 
tion ; a few drops of a saturated solution of boric acid 
should be dropped into them every four hours, and 
the nose should be kept clean by means of an antiseptic 
such as the official antiseptic solution. During des- 
quamation the skin should be anointed with cacao 
butter. The treatment in other respects consists in 
the combating of the symptoms as they arise. 



212 FEVER NURSING. 

The Diet during the febrile movement should be 
entirely fluid (milk, broths and the like), and the 
drinking of cool water is to be encouraged. As con- 
valescence progresses a gradual return to solid diet is 
proper. 

The nursing applicable to the other infectious exan- 
themata is equally suited to measles. 

German Measles. 

Synonyms. — Roseola; Rubella; Rotheln. 

Definition. — An acute, infectious febrile disease, ac- 
companied by a maculo-papular eruption and enlarge- 
ment of the lymph-glands of the neck. Roseola re- 
sembles both measles and scarlet fever in its symptoms, 
but it is a distinct disease. 

Causation. — This disease occurs most frequently in 
children, although it may be contracted by adults; it 
is most commonly observed during the cold months. 
Its specific cause has not been discovered, but the in- 
fection seems to be given off in the expired air and 
from the skin. Usually one attack affords protection 
against subsequent infection. 

The Eruption appears upon the first or second day 
of the disease, first upon the forehead, and spreads 
quickly over the face, neck, trunk, and, finally, the 
extremities. It is in the form of round, pinkish points 
one-sixteenth to one-fourth of an inch in diameter, 
slightly elevated, and at first it disappears on pressure. 
The spots may be aggregated into blotches resembling 
the rash of measles, though they are less frequently 



THE EXANTHEMA TA. 213 

crescent-shaped, or into a diffuse redness resembling 
scarlet fever. The rash lasts from one to seven days, 
and may fade in one place before appearing in another. 
Occasionally some of the papules may turn into vesicles 
or pustules. Desquamation seldom takes place. 

Course and Symptoms. — The incubation period is 
from one to three weeks; its average is about ten 
days. The invasion resembles that of measles, but is 
less severe; the appearance of the rash may be the 
first symptom. The onset is marked by chilly feelings, 
slight fever, headache, nausea, catarrhal inflammation 
of the mucous membrane lining the nose, throat and 
eyes, and swelling of the lymph-glands of the neck, 
rarely of those of the groins and axillae. When the 
rash is fully developed the fever may reach 102 to 
103 F. (38.9 to 39. 5 C), and all the symptoms are 
accentuated. After a few days the rash fades and the 
symptoms disappear. 

Complications and relapses are rare. 

Prevention. — The patient should be kept alone in a 
darkened room, if the eyes are affected, for ten days 
or two weeks, but the thorough disinfection necessary 
during and after measles and scarlet fever is not 
required. 

Treatment is usually unnecessary, but the patient 
should be kept in bed if possible. 

The Diet should be regulated in accordance with the 
patient's condition; the nursing may be conducted 
according to general rules. 



214 FEVER NURSING. 

The " Fourth Disease " of Dukes. 

This is considered by Dukes to be an independent 
disease of mild character which simulates mild scarla- 
tina, but differs from it in that its incubation period is 
much longer, being from nine to twenty-one days, and 
in its lack of prodromal symptoms. The eruption re- 
sembles that of scarlatina except that it begins upon 
the face; it is usually followed by profuse desqua- 
mation. 

Many authorities doubt the existence of this as a 
separate disease, and it is certain that, before its 
identity can be established beyond question, further 
study must be made of German measles. 

No especial consideration of the treatment or nurs- 
ing of " Fourth Disease " is necessary. 

Epidemic Cerebrospinal Meningitis. 

Synonyms. — Cerebrospinal Fever; Spotted Fever; 
Malignant Purpuric Fever; Petechial Fever. 

Definition. — An acute infectious fever appearing 
usually in epidemics and characterized by inflamma- 
tion of the membranes of the brain and spinal cord and 
commonly by an eruption. 

Causation. — The disease is most likely to appear in 
crowded localities amid unsanitary surroundings, and 
is most often seen in the cold months. Children are 
more prone to contract the infection than grown per- 
sons. The specific cause of this variety of meningitis 
is a bacillus which reaches the membranes of the brain 
and spinal cord through the nose or, having been 



THE EXANTHEMATA. 2 1 5 

breathed into the lungs, finds access to the blood- 
stream and is carried by this medium. The contagion 
is probably not transmitted by the excreta or from one 
person to another. 

Course and Symptoms. — The period of incubation 
is not certainly known. The onset is sudden and ac- 
companied by a chill followed by fever, severe pain 
in the back of the head, projectile vomiting, soreness 
at the back of the neck, and inclination to bend the 
head backward. There are various symptoms refer- 
able to the eyes : dread of light, squint, falling of the 
upper lid, unequal pupils, and movements of the eye- 
ball from side to side. Sounds annoy the patient. 
There is often nose-bleed, and fever-sores upon the 
lips are frequent. Delirium soon appears. 

The temperature curve shows great irregularity, 
being high at times, then dropping to normal only to 
rise suddenly again. The typical pulse is slow in com- 
parison with the height of the fever, but some patients 
exhibit a rapid heart-action. 

Small petechiae or larger purpuric spots may appear 
upon the body, and there may be erythematous patches. 
During the disease there are likely to be convulsive 
movements of the extremities, and the legs are usually 
drawn up. The head is forced into the pillow, and 
the facial expression is typical (the risus sardonicus) ; 
the forehead is wrinkled and the teeth are exposed 
by the drawing outward of the corners of the mouth. 
Children are likely to make an outcry typical of the 
disease. It is a single, high, shrill cry, and when once 
heard is easily recognized. 



216 FEVER NURSING. 

The patient becomes rapidly emaciated and bed-sores 
are almost certain to ensue. The bowels are usually 
constipated, and in the late stages there may be inability 
to swallow ; in which case food must be given through 
a tube passed into the stomach through the nostril or 
by means of the rectum. As the disease progresses the 
nervous irritability ceases, and the patient becomes 
stuporous or even comatose, while there is incontinence 
of urine and faeces. 

In patients who recover the fever lasts several weeks 
and then gradually falls ; as this takes place the symp- 
toms slowly ameliorate. Relapses sometimes occur. 

Convalescence is protracted. 

Different varieties of the disease may occur as 
follows : 

(a) The Mild Type, with dizziness, headache, stiff- 
ness of the neck, and low temperature. 

(&) The Intermittent Type, in which the symptoms 
improve at intervals of a few days, but recur. 

(c) The Malignant Type, in which haemorrhages 
take place into the skin, the symptoms are intense, and 
death takes place within a few hours. 

(d) The Chronic Type, which may last for several 
months with severe symptoms and marked emaciation. 

Complications. — Pneumonia is the most common of 
these. Patients may recover with deafness or blind- 
ness and in children physical and mental development 
are frequently interfered with. 

Treatment. — Isolation in a quiet, cool (about 65° 
F. — 18.3 C), darkened room is necessary. Gauze 



THE EXANTHEMATA. 2 1 7 

should be employed in the place of handkerchiefs, and 
after being used, placed in paper bags and quickly 
burned. All discharges from the nose, throat and 
mouth should be disinfected. The head must be shorn 
and an ice-cap applied, and cold applications may be 
made to the spine. The delirium and convulsions 
should be controlled by sedatives and the temperature 
by cold sponging. 

During convalescence the different tonics are indi- 
cated. 

The Diet. — The nurse should do her utmost to main- 
tain the nutrition of the patient by the frequent admin- 
istration of nourishing foods in fluid or semi-fluid 
form. When swallowing has become impossible, feed- 
ing by the rectum must be employed, and if the patient 
is delirious he should be fed by nasal gavage {see page 
157). During the stage of convalescence it is neces- 
sary that the patient should receive liberal feeding in 
order that he may regain his strength as rapidly as 
possible. 

The nursing otherwise should be conducted along 
the usual lines. 



CHAPTER IX. 

THERMIC FEVER. 

Heat Exhaustion: Insolation. 

Synonyms. — Sun-stroke; Heat-stroke; Heat Pros- 
tration. 

Definition. — A condition of prostration caused by 
exposure to intense heat. 

Causation. — Thermic fever is most common in adult 
males, probably because of their greater liability to 
exposure and tendency to alcoholic habits. It also 
occurs frequently in infants. It is predisposed to by 
over-indulgence in exercise, food and alcohol. Sol- 
diers on the march, stokers in the fire-rooms of steam- 
ships, and bakers and others whose occupations neces- 
sitate exposure to the sun or to extremes of artificial 
heat, are frequent sufferers. 

Heat Exhaustion. 
Course and Symptoms. — This affection is the re- 
sult of continued exposure to high temperatures, espe- 
cially when combined with muscular exertion, and is 
characterized by prostration, collapse, subnormal tem- 
perature (95 to 97 F.— 35 to 36.1 ° C), and small, 
quick pulse; the surface of the body is usually cool 
and in severe cases there may be delirium. 

218 



THERMIC FEVER. 219 

Insolation. 

Course and Symptoms. — In the milder type of this 
affection the onset is marked by headache, dizziness, 
prostration, and possibly nausea and vomiting. Par- 
tial or complete loss of consciousness may follow. The 
skin is flushed, hot and dry, the temperature ranges 
from 104 to 112 F. (40 to 44 ° C.) or even higher, 
the pulse is rapid and full, the breathing may be diffi- 
cult and stertorous, and the pupils are usually con- 
tracted. In the fatal cases the loss of consciousness 
becomes more profound, the heart weaker, the respira- 
tion rapid and shallow, and death may supervene within 
from twelve to thirty-six hours. In favorable cases a 
fall in temperature is accompanied by a remission of 
the other symptoms. Complete recovery may ensue, 
or the patient may be left with nervous and mental 
disturbances varying from simple loss of memory to 
insanity. A common sequel is inability to bear even 
slight degrees of heat; individuals with this idiosyn- 
crasy have been known to become very uncomfortable 
at as low a temperature as 8o° F. (26.7 C). 

In severe instances the patient may die suddenly, or 
within a short time, with all the symptoms of heart- 
failure, such as rapid, almost imperceptible pulse, ex- 
treme dyspnoea, and unconsciousness. 

Prevention consists in the avoidance of extreme 
heat, abstinence from alcohol, over-eating, and over- 
work ; plenty of water should be drunk, frequent baths 
are advisable, and the clothing should be light. 

The Treatment of Heat Exhaustion consists in rest 
in a cool place and stimulation. 



220 FEVER NURSING. 

The Treatment of Thermic Fever consists in en- 
deavors to lower the body temperature as rapidly as 
possible. If a bath-tub is available, the patient should 
be immersed in cool water and rubbed vigorously with 
lumps of ice, in the hands of at least two attendants. 
If no tub is at hand, the patient should be placed in the 
shade, and cool water dashed upon him. Syncope 
may be controlled by hypodermatic injections of alco- 
hol, and such other stimulants as ether and ammonia 
may be given by the same means ; artificial respiration 
may be necessary. If tubbing is impossible, ice water 
enemata may accomplish good results; sprinkle baths 
from a watering pot, held at a height, or from a hose, 
seem to have a good effect, probably from the stimula- 
tion caused by the impact of the water against the 
body. 

The temperature should be taken at frequent inter- 
vals, and when it has reached 102 F. (38.9 C.) the 
hydriatic measures should be stopped, for otherwise 
the temperature is likely to fall to a subnormal level, 
and collapse may result. The patient should now be 
put to bed, given a cathartic, and catheter ized if neces- 
sary ; he should remain in bed and on a light diet for 
a few days. Subsequent rises of temperature may be 
controlled by cold sponging or tub baths, if necessary ; 
otherwise no departure from the general principles of 
nursing in febrile conditions need be made. 



INDEX. 



Abdominal typhus, see Enteric 

fever 
Abscess in enteric fever, 97 
Acute articular rheumatism, 159 

febrile jaundice, see Weil's 
disease 

miliary tuberculosis, 127 
Ambulatory typhoid, 88, 94 
Antipyretic drugs in fever, 33 
Antiseptics, 73 
Antitoxin, diphtheria, 153 
Antityphoid inoculation, 100 

Baths, bed or slush, 38 
in enteric fever, 101 
mustard, 53 
sheet, 41 
sponge, 39 
sprinkle, 41 . 
towel, 42 
tub, 34 
Bed and bed clothing in fe- 
brile disease, 69 
Bed-sores, prevention and treat- 
ment of, 46 
Beverages, 51 

Black death, see Typhus fever 
Blood-poisoning, see Septicaemia 
Brand bath, so-called, 101 
Breakbone fever, see Dengue 
Broncho-pneumonia, 140, 211 
Bubonic plague, 174 

causation, 174 

course and symptoms 

175 
definition, 174 
pneumonic type, 175 
prevention, 175 
treatment, 176 



Calomel in fevers, 49 
Camp fever, see Typhus fever 
Catheterization, 51 
Cellulitis in erysipelas, 164 
Centigrade and Fahrenheit scale 
conversion, 20 
scale of thermometry, 20 
Cerebrospinal fever, 214 
Charting, 28 
Chicken-pox, 206 

causation, 206 

course and symptoms, 

207 
definition, 206 
eruption, 206 
prevention, 207 
treatment, 208 
Child-bed fever, see Puerperal 

fever 
Chill, 8 

treatment, 53 
Chills and fever, see Malarial 

fever 
Circulatory system, symptoms 
referable to, 1 1 
treatment, 49 
Cold externally for reducing 

temperature, 34 et seq. 
Coma, 17 

vigil, 16 
Consumption, 129 
Convalescence, diet in, 62, 85 

temperature In, 4 
Convulsions, treatment of, 53 
Cream of tartar lemonade, 51 
Crisis in fever, 4 
Croup kettle, 155 
membranous, 158 
tent, 155 
Currie-Jurgensen bath, 101 



221 



222 



INDEX. 



Dandy fever, see Dengue 
Defervescence, 3 
Delirium, 15 

treatment, 54 
Dengue, 186 

causation, 186 

course and symptoms, 187 

definition, 186 

diet in, 188 

prevention, 188 

treatment, 188 
Deodorants, 73 
Diagnosis of fever, 19 
Diarrhoea, treatment of, 49 
Diet charting, 31 

in convalecsence, 62, 85 

in febrile disease, 58, 61 

list for convalescents, 63 
Digestion, symptoms referable 
to organs of, 11 

treatment, 48 
Diphtheria, 145 

causation, 145 

complications, 148 

course and symptoms, 146 

culture-taking from throat 
in, technique of, 149 

definition, 145 

diagnosis, 149 

diet in, 157 

false, 158 

immunization in, 153 

laryngeal, 147, 155 

malignant, 147 

nasal, 148 

paralysis following, 148 

prevention, 150 

treatment, 153 
local, 154 
Disinfectants, 73 et seq. 
Disinfection during and after 
febrile diseases, 73 et seq. 

of excreta, etc., 78 

of rooms, bedding, etc., 
technique, 75 

of waterclosets, drains, 
sinks and privies, 81 



Distention of stomach and 

bowels by gas, 48, 104 
Dizziness in fever, 14, 54 
Drains, disinfection of, 81 
Dukes, fourth disease of, 214 

Ears, symptoms referable to, 17 
treatment, 56 

Eggs, 60 

Elimination, 32, 49, 50, 61 

Empyema, 140 

Enemata, 49 

ice-water, 44 

Enteric fever, 82 

abortion in, 96 

afebrile, 92 

baths in, 101 

causation, 82 

in children, 98, 103 

clinical chart, 90 

complications, 89, 97 

treatment, 103 
convalescence, 99 
course, 89 
definition, 82 
diet in, 85, 105 

for convalescents, 

85 
drugs in, 101, 102 
epistaxis in, 87 
eruption, 92 
facial appearance, 92 
inoculation in, 100 
menstruation in, 96 
nursing in, 83, 106 
in old persons, 99 
onset, 87 

precautions, 84, 86 
prevention, 99 
recrudescences, 91, 105 
relapses, 92, 105 
symptoms, 89 
temperature in, 89 
tongue, 93 
treatment, 100 
typical case of, 93 
Epidemic catarrhal fever, see 
Influenza 



INDEX. 



223 



Epidemic cerebrospinal menin- 
gitis, see Meningitis 
Epistaxis, treatment of, 56 
Erysipelas, 163 

causation, 163 

cellulitis in, 164 

complications, 165 

cutaneous, 163 

definition, 166 

diet in, 166 

phlegmonous, 164 

treatment, 165 

varieties, 163 

wandering, 164 
Exanthemata, the, 189 
Eyes, symptoms referable to, 17 

treatment, 57 

Fahrenheit scale of thermom- 
etry, 20 
False diphtheria, 158 
Famine fever, see Relapsing 

fever 
Feeding in febrile disease, 58 
et seq. 
forced, 135, 157 
Fever, adynamic, 3 

and ague, see Malarial 

fever 
asthenic, 3 
causes, 1 
continued, 3 
convulsions in, 8 
definition, 1 
diagnosis, 19 
dynamic, 3 
elimination in, 32, 49, 50, 

61 
intermittent, 3, 178 
inverse, 3 
physiology, 2 
remittent, 3 
sores, 9 
sthenic, 3 
symptoms, 9 et seq. 

referable to the circu- 
latory system, 
11, 49 



Fever, symptoms referable to 

the mucous 

membranes, 9, 47 

nervous system, 

13, 53 
organs of diges- 
tion, 11, 48 
respiratory system, 

12, 50 
skin, 9, 45 
special senses, 17, 

56 
urinary system, 13, 
50 
tissue waste in, 17 
treatment, general, 32 
varieties, 2 
Flax-seed poultices, to make, 

143 
Formaldehyde gas as a disin- 
fectant, 74, 78 
Fourth disease of Dukes, 214 
Furniture of sick-room, 69 

Gavage, 135, 157 
General directions, 65 

treatment, 32 
German measles, 212 

causation, 212 

course and symptoms, 
213 

definition, 212 

diet in, 213 

eruption, 212 

prevention, 213 

treatment, 213 

Haemorrhage, intestinal, in en- 
teric fever, 97, 103 
pulmonary, treatment of, 133 
Headache, 14 

treatment, 54 
Hearing, symptoms of fever re- 
ferable to, 17, 56 
Heat exhaustion, course and 
symptoms, 218 
see also Thermic fever 
production, 2 
radiation, 2 



224 



INDEX. 



Heat prostration, see Thermic 

fever 
Heat-stroke, see Thermic fever 
Herpes labialis, 9 
Hiccough, 17 

treatment, 55 
Hospital fever, see Typhus fever 
Hydrotherapy in fever, 34 
Hyperpyrexia, 7 

Ice bags, 43 

coils, 43 

compresses, 43 

pack, 42 

rub, 42 
Ice-water enemata, 44 
Index, 229 
Infections of continued type, 82 

with local manifestations, 
138 

of intermittent type, 177 
Inflammatory rheumatism, 159 
Influenza, 119 

causation, 120 

complications 121 

course and symptoms, 120 

definition, 119 

diet in, 122 

prevention, 122 

treatment, 122 

types, 120 
Inhalation of hot steam in 

diphtheria, 155 
Insolation, 219 

course and symptoms, 219 

prevention, 219 

treatment, 219 
Intermittent fever, 178 

type, infections of, 177 
Introduction, 1 
Intubation in diphtheria, 156 
Irrigation in diphtheria, 154 

in phlegmonous erysipelas, 
165 

in puerperal fever, 170 

rectal, with saline solution, 
54 
Isolation, general care of pa- 
tient in, 150 



Jail fever, see Typhus fever 
Jaundice, acute febrile, see 
Weil's disease. 

Kaolin cataplasm, application 

of to chest, 143 
Koplik's spots, 209 

La grippe, see Influenza 
Laryngitis, tuberculous, 130, 135 
Lung fever, see Pneumonia 
Lysis in fever, 3 

Malarial cachexia, 177, 181, 182 
fever, 177 

aesti vo-autumnal, 177, 

178 
causation, 177 
chronic, 177, 181, 182 
clinical chart, 180 
course and symptoms, 

178 
definition, 177 
pernicious, 177, 180, 
182 
types of, 181 
prevention, 182 
quartan, 177, 178 
quotidian, 177 
tertian, 177, 178 
treatment, 182 
varieties, 177 
Malignant adenitis, see Bubonic 
plague 
purpuric fever, see Menin- 
gitis, epidemic cerebro- 
spinal 
Malta fever, 123 

causation, 123 
complications, 124 
course and symptoms, 

123 
definition, 123 
diet in, 124 
prevention, 124 
treatment, 124 
Measles, 208 
black, 210 
causation, 208 



INDEX. 



22: 



Measles, clinical chart, 210 
complications, 210 
course and symptoms, 209 
definition. 208 
diet in, 212 

diagnosis of, early, 209 
eruption, 209 
German, 212 
hemorrhagic, 210 
prevention, 211 
treatment, 211 
Medication charting, 31 
Mediterranean fever, see Malta 

fever 
Membranous croup, 158 
Meningitis, epidemic cerebro- 
spinal, 214 
causation, 214 
chronic, 216 
complications, 216 
course and symp- 
toms, 215 
definition, 214 
diet in, 217 
eruption, 215 
intermittent type, 

216 
malignant, 216 
mild type, 216 
treatment, 216 
varieties, 216 
Menstruation in pulmonary tu- 
berculosis, 130 
in enteric fever, 96 
Mercury bichloride as a disin- 
fectant, 80 
Milk, diet, 58, 60 
Morbilli, see Measles 
Mountain fever, 124 

causation, 124 

course and symptoms. 

125 
definition, 124 
diet in, 127 
eruption, 126 
prevention, 126 
treatment, 126 



Mucous membranes, symptoms 
referable to, 9 
treatment, 47 
Mumps, 172 

causation, 172 

course and symptoms, 173 

definition, 172 

diet in, 174 

metastases, 172, 173 

prevention, 173 

treatment, 173 
Mustard baths for children, 53 

Neapolitan fever, see Malta 

fever 
Nervous fever, see Enteric 
fever 
system, symptoms referable 
to, 13 
treatment, 53 
Neuritis complicating enteric 

fever, 98 
Night-sweats, treatment of, 133 
Nose, treatment of symptoms 

referable to, 56 
Nose-bleed, treatment of, 63 
Nurse, behaviour of, 65 
duties of, 70, 71, 150 

Obstetric nursing, 169 

Pack, ice, 42 

Pains, general, 14, 2Z 

treatment, 54 
Paludal fever, see Malarial 

fever 
Paludism, see Malarial fever 
Paratyphoid fever, 108 
Parotitis, epidemic, see Mumps 
Patient, care of, 70 
Perforation of bowel in enteric 

fever. 97, 104 
Peritonitis in enteric fever, 97, 

104 
Pest, the, see Bubonic plague 
Petechial fever, see Meningitis, 

epidemic cerebro-spinal 



226 



INDEX. 



Phlebitis in enteric fever, 98, 

101 
Phthisis, chronic, see Tubercu- 
losis, chronic pulmonary- 
Plague, bubonic, 174 
Pneumonia, 138 
causation, 138 
clinical chart, 141 
complicating enteric fever, 

98 
complications, 140 
course and symptoms, 149 
croupous, 138 
definition, 138 
diet in, 145 
fibrinous, 138 
in infants, 142 
nursing in, 145 
in old persons, 142 
prevention, 142 
treatment, 143 
varieties, 142 
Pneumonitis, see Pneumonia 
Privies, disinfection of, 81 
Pseudo-diphtheria, 158 
Puerperal fever, 168 

causation, 169 
prevention, 169 
treatment, 1 70 
infection, see Puerperal 

fever 
septicaemia, see Puerperal 
fever 
Pulse, characters of, 24, 25 
charting, 29 
dicrotic, 25 

factors influencing, 24 
intermittent, 26 
irregular, 26 
normal, 25, 26 
qualities to be noted in 

taking, 25 
table of, with correspond- 
ing temperature, 11 
taking, 2/ 
tension, 26 

thickening of artery in, 26 
variations in, 24 



Putrid fever, see Typhus fever 

sore throat, see Diphtheria 
Pyaemia, 170 

causation, 170 

course and symptoms, 171 

definition, 170 

local manifestations, 171 

prevention, 1 72 

treatment, 172 
Pyrexia, 1 

Reaumur, scale of thermometry, 

20 
Recrudescence in fever, 3 
Rectal irrigation with saline 

solution, 5 1 
Recurrent typhus, see Relapsing 

fever 
Relapse in fever, 3 
Relapsing fever, 183 

causation, 183 
clinical chart, 185 
complications, 185 
course and symptoms, 

184 
definition, 183 
prevention, 185 
treatment, 186 
Respiration charting, 29 
normal, 27, 28 
qualities to be noted in 

taking, 27, 28 
taking, 28 
Respiratory system, symptoms 
referable to, 12 
treatment, 50 
Rheumatic fever, 159 
Rheumatism, acute articular, 

159 
causation, 159 
clinical chart, 161 
complications, 160 
course and symp- 
toms, 159 
definition, 159 
diet in, 162 
hyperpyrexia in, 
160 



INDEX. 



227 



Rheumatism, acute articular, 
prevention, 160 
treatment, 160 
inflammatory, 159 
Rigor, treatment of, 53 
Rock fever, see Malta fever 
Room, preparation of for a case 

of contagious disease, 149 
Roseola, see German measles 
Rotheln, see German measles 
Rubella, see German measles 
Rubeola, see Measles 

St. Anthony's fire, see Erysipelas 

Salt solution, normal, injection 
of, 43 

Scarlatina, 189, 190 

Scarlet fever, 189 

anginose, 192 
causation, 189 
clinical chart, 192 
complications and se- 
quelae, 193 
course and symptoms, 

191 
definition, 189 
desquamation in, 192 
diet in, 196 
eruption, 190 
hemorrhagic, 193 
malignant, 193 
nephritis in, 193 
otitis in, 194 
prevention, 195 
severe forms, 192 
treatment, 196 
Septicaemia, 166 
causation, 166 

course and symptoms, 
167 
definition, 166 
diet in, 168 
prevention, 168 
progressive, 167 
treatment, 168 
Seven-day fever, see Relapsing 

fever 
Ship fever, see Typhus fever 



Sick-room, the, 65 

Sight, symptoms referable to 

sense of, 18 
Singultus, 17 
Sinks, disinfection of, 81 
Skin, symptoms referable to, 9 

treatment, 45 
Smallpox, 197 

causation, 197 

clinical chart, 199 

confluent, 200 

course and symptoms, 198 

definition, 197 

diagnosis of, early, 199 

eruption, 198 

general management, 204 

hasmorrhagic, 201 

malignant, 201 

prevention, 201 

treatment, 206 
Smell, symptoms referable to 

sense of, 17 
Sordes, 10 

Special senses, symptoms re- 
ferable to, 17 

treatment, 56 
Spine, typhoid, 98 
Spirillum fever, see Relapsing 

fever 
Spotted fever, no, 124, 214 
Sputum, disinfection of, 79 
Steam as a disinfectant, 76 
Stools, disinfection of, 79, 84 
Subsultus tendinum, 16 
Sulphur dioxide gas as a dis- 
infectant, 74, 77 
Sunstroke, see Thermic fever 
Swamp fever, see Malarial 
fever 

Taste, symptoms referable to 

sense of, 17 
Temperature, body, 3 et seq. 

in axilla, 22, 23 

charting, 29 

charts, 29 

in groin, 2^ 

in mouth, 22 



228 



INDEX. 



Temperature limits, 6 

normal variations, 5 et seq. 

ranges, 7 

in rectum, 22, 23 

reduction, 33 et seq. 

subnormal, 7 

table of, with correspond- 
ing pulse, 11 

technique of taking, 22 
Tent for hot steam inhalation, 

iS5 
Thermic fever, 218 

causation, 218 

definition, 218 

treatment, 220 
Thermometer, the, 19 et seq. 
Thermometers, care of, 21 
Thermometry, 19 
scales of, 20 
Thrombosis in enteric fever, 

97, 104 
Tick fever, see Mountain fever 
Tongue, care of, 47 
Tracheotomy in diphtheria, 157 
Tuberculosis, acute, general, 
127 
miliary, 127 

causation, 127 

course and symptoms, 

127 
definition, 127 
diet in, 128 
treatment, 128 
varieties, 128 
chronic pulmonary, 129 
causation, 129 
course and symp- 
toms, 129 
definition, 129 
diet in, 134 
prevention, 131 
treatment, 132 
Turpentine stupes, application 

of, 48 
Tympanites, treatment of, 48 

in enteric fever, 104 
Typhoid fever, see Enteric 
fever 



Typhoid pneumonia, 142 
spine, 98 
walking, 88, 94 

Typhus fever, no 

causation, no 
clinical chart, 113 
course and symptoms 

of, III 
definition, no 
diet, 114 
eruption, 112 
prevention, 114 
treatment, 114 

Undulant fever, see Malta 

fever 
Urinary examinations, chart- 
ing, 30 
system, symptoms refer- 
able to, 13 
treatment, 50 
Urine, disinfection of, '79 

specimens of for examina- 
tion, 50 
treatment of retention of, 
5i # 
Vaccination, 201 

complications, 204 
technique, 202 
Vaccinia, 203 

generalized, 203 
Varicella, see Chicken-pox 
Variola, see Smallpox 
Varioloid, 201 
Ventilation, 67 
Vertigo, 14, 54 
Visitors, 71 
Vomiting, treatment of, 48 

Walking typhoid, 88, 94 
Water-closets, drains, sinks and 

privies, disinfection of, 81 
Weil's disease, 109 

definition and charac- 
teristics, 109 
diet in, no 
treatment, no 



INDEX. 229 

Widal reaction in enteric fever, Yellow fever, course and symp- 
99 toms, 115 

definition, 115 
diet in, 119 
Yellow fever, 115 prevention, 118 

causation, 116 treatment, 118 

clinical chart, 116 varieties, 118 



APH 22 1908 



